{"id":139,"date":"2026-07-22T09:58:55","date_gmt":"2026-07-22T09:58:55","guid":{"rendered":"https:\/\/tpwv.comprofs.nl\/?page_id=139"},"modified":"2026-07-22T10:24:57","modified_gmt":"2026-07-22T10:24:57","slug":"medical-history","status":"publish","type":"page","link":"https:\/\/tpwv.comprofs.nl\/?page_id=139","title":{"rendered":"Medical History"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated 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                       <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_6'  action='\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F139' data-formid='6' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_1'>Name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_6_1' type='text' value='' class='large'  aria-describedby=\"gfield_description_6_1\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_6_1'>Why is a health questionnaire important for your dentist and dental hygienist?\n\nComplaints in the mouth can be caused by illness or medication use.\n\nIf you are ill or take medication, this may limit dental treatment or require precautionary measures. It is important that your dentist takes this into account.\n\nAlways inform your dentist if anything has changed in your health or medication use. Your data is covered by medical confidentiality and will therefore be treated confidentially.\n\nBring a recent medication list with you to every visit to your dentist. You can request a recent list from your pharmacist.<\/div><\/div><fieldset id=\"field_6_3\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gender:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_3'>\n\t\t\t<div class='gchoice gchoice_6_3_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Female'  id='choice_6_3_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_3_0' id='label_6_3_0' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_3_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Male'  id='choice_6_3_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_3_1' id='label_6_3_1' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_5\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_5'>Date of birth:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_5' id='input_6_5' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/jjjj' aria-describedby=\"input_6_5_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_5_date_format' class='screen-reader-text'>DD slash MM slash JJJJ<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_5' class='gform_hidden' value='https:\/\/tpwv.comprofs.nl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Has anything changed in your health in the past few months?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_15'>\n\t\t\t<div class='gchoice gchoice_6_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Yes'  id='choice_6_15_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_15_0' id='label_6_15_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='No'  id='choice_6_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_15_1' id='label_6_15_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_16\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_16'>If yes, what?<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_6_16' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_17\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever had a heart attack?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_17'>\n\t\t\t<div class='gchoice gchoice_6_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Yes'  id='choice_6_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_17_0' id='label_6_17_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='No'  id='choice_6_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_17_1' id='label_6_17_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_18'>If yes, when?<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_6_18' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_19\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you allergic to anything?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_19'>\n\t\t\t<div class='gchoice gchoice_6_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Yes'  id='choice_6_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_19_0' id='label_6_19_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='No'  id='choice_6_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_19_1' id='label_6_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_20\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_20'>If yes, what?<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_6_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you suffer from palpitations?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_21'>\n\t\t\t<div class='gchoice gchoice_6_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Yes'  id='choice_6_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_21_0' id='label_6_21_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='No'  id='choice_6_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_21_1' id='label_6_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you being treated for high blood pressure?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_11'>\n\t\t\t<div class='gchoice gchoice_6_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Yes'  id='choice_6_11_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_11_0' id='label_6_11_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='No'  id='choice_6_11_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_11_1' id='label_6_11_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_12'>Lower pressure:<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_6_12' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_13'>Upper pressure:<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_6_13' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have chest pain during exertion?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_22'>\n\t\t\t<div class='gchoice gchoice_6_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Yes'  id='choice_6_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_22_0' id='label_6_22_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='No'  id='choice_6_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_22_1' id='label_6_22_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you become short of breath when lying flat in bed?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_23'>\n\t\t\t<div class='gchoice gchoice_6_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Yes'  id='choice_6_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_23_0' id='label_6_23_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_6_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_23_1' id='label_6_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_24\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have a heart valve defect or an artificial heart valve?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_24'>\n\t\t\t<div class='gchoice gchoice_6_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Yes'  id='choice_6_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_24_0' id='label_6_24_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='No'  id='choice_6_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_24_1' id='label_6_24_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have a congenital heart defect?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_25'>\n\t\t\t<div class='gchoice gchoice_6_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Yes'  id='choice_6_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_25_0' id='label_6_25_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='No'  id='choice_6_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_25_1' id='label_6_25_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever had endocarditis?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_26'>\n\t\t\t<div class='gchoice gchoice_6_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Yes'  id='choice_6_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_26_0' id='label_6_26_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='No'  id='choice_6_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_26_1' id='label_6_26_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_27\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have a pacemaker (or ICD) or neurostimulator?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_27'>\n\t\t\t<div class='gchoice gchoice_6_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Yes'  id='choice_6_27_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_27_0' id='label_6_27_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='No'  id='choice_6_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_27_1' id='label_6_27_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_28\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever fainted during dental or medical treatment?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_28'>\n\t\t\t<div class='gchoice gchoice_6_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Yes'  id='choice_6_28_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_28_0' id='label_6_28_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='No'  id='choice_6_28_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_28_1' id='label_6_28_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_29\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have epilepsy?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_29'>\n\t\t\t<div class='gchoice gchoice_6_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Yes'  id='choice_6_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_29_0' id='label_6_29_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='No'  id='choice_6_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_29_1' id='label_6_29_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever had a cerebral hemorrhage, stroke, or TIA?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_30'>\n\t\t\t<div class='gchoice gchoice_6_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Yes'  id='choice_6_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_30_0' id='label_6_30_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='No'  id='choice_6_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_30_1' id='label_6_30_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_31\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have lung problems such as asthma, bronchitis, or chronic cough?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_31'>\n\t\t\t<div class='gchoice gchoice_6_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Yes'  id='choice_6_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_31_0' id='label_6_31_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='No'  id='choice_6_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_31_1' id='label_6_31_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_32\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have diabetes?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_32'>\n\t\t\t<div class='gchoice gchoice_6_32_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Yes'  id='choice_6_32_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_32_0' id='label_6_32_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_32_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='No'  id='choice_6_32_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_32_1' id='label_6_32_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_33'>If yes, do you use insulin?<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_6_33' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_34\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have anemia?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_34'>\n\t\t\t<div class='gchoice gchoice_6_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Yes'  id='choice_6_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_34_0' id='label_6_34_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='No'  id='choice_6_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_34_1' id='label_6_34_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_35\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever had prolonged bleeding after having teeth removed or after surgery?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_35'>\n\t\t\t<div class='gchoice gchoice_6_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Yes'  id='choice_6_35_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_35_0' id='label_6_35_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='No'  id='choice_6_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_35_1' id='label_6_35_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_37\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you had hepatitis, jaundice, or another liver disease?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_37'>\n\t\t\t<div class='gchoice gchoice_6_37_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Yes'  id='choice_6_37_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_37_0' id='label_6_37_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_37_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='No'  id='choice_6_37_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_37_1' id='label_6_37_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have kidney disease?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_36'>\n\t\t\t<div class='gchoice gchoice_6_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Yes'  id='choice_6_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_36_0' id='label_6_36_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='No'  id='choice_6_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_36_1' id='label_6_36_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_38\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have rheumatism and\/or chronic joint problems?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_38'>\n\t\t\t<div class='gchoice gchoice_6_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Yes'  id='choice_6_38_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_38_0' id='label_6_38_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='No'  id='choice_6_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_38_1' id='label_6_38_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_39\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you been irradiated because of a tumor in the head or neck?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_39'>\n\t\t\t<div class='gchoice gchoice_6_39_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Yes'  id='choice_6_39_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_39_0' id='label_6_39_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_39_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='No'  id='choice_6_39_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_39_1' id='label_6_39_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_40\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you smoke?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_40'>\n\t\t\t<div class='gchoice gchoice_6_40_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Yes'  id='choice_6_40_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_40_0' id='label_6_40_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_40_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='No'  id='choice_6_40_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_40_1' id='label_6_40_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_41\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_41'>If yes, how many per day?<\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_6_41' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_42\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you pregnant?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_42'>\n\t\t\t<div class='gchoice gchoice_6_42_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Yes'  id='choice_6_42_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_42_0' id='label_6_42_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_42_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='No'  id='choice_6_42_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_42_1' id='label_6_42_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you breastfeeding?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_43'>\n\t\t\t<div class='gchoice gchoice_6_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Yes'  id='choice_6_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_43_0' id='label_6_43_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='No'  id='choice_6_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_43_1' id='label_6_43_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_44\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have a disease or condition that has not been asked about?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_44'>\n\t\t\t<div class='gchoice gchoice_6_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Yes'  id='choice_6_44_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_44_0' id='label_6_44_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='No'  id='choice_6_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_44_1' id='label_6_44_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_45\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_45'>If yes, which one?<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_6_45' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_46\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever used a medicine for osteoporosis, such as a bisphosphonate or denosumab?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_46'>\n\t\t\t<div class='gchoice gchoice_6_46_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Yes'  id='choice_6_46_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_46_0' id='label_6_46_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_46_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='No'  id='choice_6_46_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_46_1' id='label_6_46_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_47\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_47'>If yes, which one?<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_6_47' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_48\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you take medication?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_48'>\n\t\t\t<div class='gchoice gchoice_6_48_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='Yes'  id='choice_6_48_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_48_0' id='label_6_48_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_48_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='No'  id='choice_6_48_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_48_1' id='label_6_48_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_49\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_49'>If yes, which one?<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_6_49' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_50\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_50'>Current date:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_50' id='input_6_50' type='text' value='' class='datepicker gform-datepicker ymd_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='jjjj-mm-dd' aria-describedby=\"input_6_50_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_50_date_format' class='screen-reader-text'>JJJJ dash MM dash DD<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_50' class='gform_hidden' value='https:\/\/tpwv.comprofs.nl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_51\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Privacy policy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_51.1' id='input_6_51_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_51_1' >I agree<\/label><input type='hidden' name='input_51.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_51.3' value='5' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_6_52\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class=\"ginput_container ginput_container_signature\"><input type='hidden' value='' name='input_52' id='input_6_52_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_6_52_Container' class='gfield_signature_container' style='height:180px; width:300px; ' ><canvas id=\"input_6_52\" width=\"300\" height=\"180\" style=\"border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/tpwv.comprofs.nl\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;\" tabindex=\"0\" aria-label=\"Signature pad\" ><\/canvas><\/div><div id='input_6_52_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id='input_6_52_resetbutton' src='data:image\/png;base64,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' 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