{"id":1865,"date":"2024-04-05T12:27:19","date_gmt":"2024-04-05T09:27:19","guid":{"rendered":"https:\/\/www.revitalizeinturkey.com\/\/?page_id=1865"},"modified":"2026-04-08T15:51:26","modified_gmt":"2026-04-08T15:51:26","slug":"medical-history-form","status":"publish","type":"page","link":"https:\/\/revitalizeinturkey.com\/de\/medical-history-form\/","title":{"rendered":"Medical History Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1865\" class=\"elementor elementor-1865\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-b51b1a0 e-flex e-con-boxed e-con e-parent\" data-id=\"b51b1a0\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-4733ace elementor-widget elementor-widget-shortcode\" data-id=\"4733ace\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f61805-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"61805\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/de\/wp-json\/wp\/v2\/pages\/1865#wpcf7-f61805-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"61805\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f61805-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<p><link rel=\"stylesheet\" href=\"https:\/\/cdnjs.cloudflare.com\/ajax\/libs\/font-awesome\/6.4.2\/css\/all.min.css\" \/>\n<\/p>\n<div id=\"patient-form\" class=\"patient-form-wrapper\">\n\t<div class=\"form-section\">\n\t\t<h3 class=\"section-title\"><i class=\"fa-solid fa-address-card\"><\/i> PATIENT DETAILS\n\t\t<\/h3>\n\t\t<div class=\"grid-row\">\n\t\t\t<div class=\"field-wrap input-icon\">\n\t\t\t\t<p><i class=\"fa-solid fa-user\"><\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Name Surname\" value=\"\" type=\"text\" name=\"patient-name\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"field-wrap input-icon\">\n\t\t\t\t<p><i class=\"fa-regular fa-calendar-days\"><\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dob\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Date of Birth\" value=\"\" type=\"date\" name=\"dob\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"field-wrap input-icon\">\n\t\t\t\t<p><i class=\"fa-solid fa-ruler-vertical\"><\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"height\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Height (ft or inch)\" value=\"\" type=\"text\" name=\"height\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"field-wrap input-icon\">\n\t\t\t\t<p><i class=\"fa-solid fa-weight-scale\"><\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"weight\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Weight\" value=\"\" type=\"text\" name=\"weight\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"field-wrap full-width input-icon textarea-icon\">\n\t\t\t\t<p><i class=\"fa-solid fa-map-location-dot\"><\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"address\"><textarea cols=\"40\" rows=\"3\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Address\" name=\"address\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"field-wrap\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"phone-home\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" id=\"phone-home\" aria-invalid=\"false\" placeholder=\"Phone Home\" value=\"\" type=\"tel\" name=\"phone-home\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"field-wrap\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"mobile\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" id=\"mobile\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Mobile\" value=\"\" type=\"tel\" name=\"mobile\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"field-wrap full-width input-icon\">\n\t\t\t\t<p><i class=\"fa-solid fa-envelope\"><\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"E-Mail Address\" value=\"\" type=\"email\" name=\"email\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-section\">\n\t\t<h3 class=\"section-title\"><i class=\"fa-solid fa-stethoscope\"><\/i> MEDICAL INFORMATION\n\t\t<\/h3>\n\t\t<p class=\"section-subtitle\">(DO YOU HAVE OR HAVE YOU HAD)\n\t\t<\/p>\n\t\t<div class=\"medical-grid\">\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"AIDS or HIV+\"><i class=\"fa-solid fa-ribbon text-red\"><\/i> AIDS\/HIV+<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"aids\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"aids\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"aids\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Anemia\"><i class=\"fa-solid fa-droplet text-red\"><\/i> Anemia<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"anemia\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"anemia\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"anemia\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Arthritis\"><i class=\"fa-solid fa-bone text-gray\"><\/i> Arthritis<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"arthritis\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"arthritis\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"arthritis\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Asthma\"><i class=\"fa-solid fa-lungs text-blue\"><\/i> Asthma<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"asthma\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"asthma\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"asthma\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Back Problems\"><i class=\"fa-solid fa-person-walking text-gray\"><\/i> Back Problems<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"back-probs\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"back-probs\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"back-probs\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Bladder Infection\"><i class=\"fa-solid fa-restroom text-blue\"><\/i> Bladder Infection<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"bladder\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"bladder\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"bladder\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Bleeding Tendency\"><i class=\"fa-solid fa-syringe text-red\"><\/i> Bleeding Tend.<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"bleeding-tend\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"bleeding-tend\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"bleeding-tend\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Blood Clots\"><i class=\"fa-solid fa-viruses text-red\"><\/i> Blood Clots<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"blood-clots\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"blood-clots\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"blood-clots\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Bronchitis\"><i class=\"fa-solid fa-lungs-virus text-blue\"><\/i> Bronchitis<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"bronchitis\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"bronchitis\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"bronchitis\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"History of cancer\"><i class=\"fa-solid fa-disease text-purple\"><\/i> History of cancer<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"cancer\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"cancer\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Diabetes\"><i class=\"fa-solid fa-cubes-stacked text-blue\"><\/i> Diabetes<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"diabetes\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"diabetes\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"diabetes\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"High Blood Pressure\"><i class=\"fa-solid fa-heart-pulse text-red\"><\/i> High Blood Pressure<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"high-bp\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"high-bp\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"high-bp\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Colitis\"><i class=\"fa-solid fa-disease text-red\"><\/i> Colitis<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"colitis\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"colitis\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"colitis\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Congenital Heart\"><i class=\"fa-solid fa-heart-crack text-red\"><\/i> Congenital Heart<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"congenital-heart\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"congenital-heart\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"congenital-heart\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Epilepsy\"><i class=\"fa-solid fa-bolt text-purple\"><\/i> Epilepsy<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"epilepsy\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"epilepsy\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"epilepsy\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Fainting Spells\"><i class=\"fa-solid fa-dizzy text-gray\"><\/i> Fainting Spells<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"fainting\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"fainting\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"fainting\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Goiter\"><i class=\"fa-solid fa-head-side-mask text-blue\"><\/i> Goiter<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"goiter\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"goiter\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"goiter\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Hay Fever\"><i class=\"fa-solid fa-seedling text-green\"><\/i> Hay Fever<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"hay-fever\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"hay-fever\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"hay-fever\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Hepatitis\"><i class=\"fa-solid fa-vial text-red\"><\/i> Hepatitis<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"hepatitis\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"hepatitis\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"hepatitis\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Kidney Disease\"><i class=\"fa-solid fa-notes-medical text-blue\"><\/i> Kidney Disease<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"kidney-disease\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"kidney-disease\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"kidney-disease\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Liver Disease\"><i class=\"fa-solid fa-flask text-purple\"><\/i> Liver Disease<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"liver-disease\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"liver-disease\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"liver-disease\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Leukemia\"><i class=\"fa-solid fa-droplet text-red\"><\/i> Leukemia<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"leukemia\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"leukemia\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"leukemia\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Migraine\"><i class=\"fa-solid fa-head-side-virus text-purple\"><\/i> Migraine<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"migraine\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"migraine\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"migraine\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Nervous Breakdown\"><i class=\"fa-solid fa-brain text-gray\"><\/i> Nervous Breakdown<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"nervous-breakdown\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"nervous-breakdown\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"nervous-breakdown\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Pneumonia\"><i class=\"fa-solid fa-lungs text-blue\"><\/i> Pneumonia<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"pneumonia\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"pneumonia\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"pneumonia\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Palpitations\"><i class=\"fa-solid fa-heart-pulse text-red\"><\/i> Palpitations<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"palpitations\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"palpitations\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"palpitations\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Pain in the Chest\"><i class=\"fa-solid fa-heart-circle-exclamation text-red\"><\/i> Pain in the Chest<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"chest-pain\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"chest-pain\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"chest-pain\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Rheumatic Heart\"><i class=\"fa-solid fa-heart text-red\"><\/i> Rheumatic Heart<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"rheumatic-heart\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"rheumatic-heart\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"rheumatic-heart\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Shortness of breath\"><i class=\"fa-solid fa-wind text-gray\"><\/i> Shortness of breath<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"shortness-breath\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"shortness-breath\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"shortness-breath\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Stomach Ulcers\"><i class=\"fa-solid fa-shield-virus text-blue\"><\/i> Stomach Ulcers<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"stomach-ulcers\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"stomach-ulcers\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"stomach-ulcers\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Stroke History\"><i class=\"fa-solid fa-brain text-purple\"><\/i> Stroke History<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"stroke\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"stroke\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"stroke\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Thyroid Disease\"><i class=\"fa-solid fa-staff-snake text-blue\"><\/i> Thyroid Disease<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"thyroid\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"thyroid\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"thyroid\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Tuberculosis\"><i class=\"fa-solid fa-lungs-virus text-blue\"><\/i> Tuberculosis<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"tuberculosis\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"tuberculosis\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"tuberculosis\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\" title=\"Cold or Flu\"><i class=\"fa-solid fa-temperature-high text-red\"><\/i> Cold or flu recently?<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"cold-flu\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"cold-flu\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"cold-flu\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"grid-row mt-20\">\n\t\t\t<div class=\"field-wrap full-width question-box\">\n\t\t\t\t<div class=\"q-title\">\n\t\t\t\t\t<p><i class=\"fa-solid fa-heart-circle-exclamation text-red\"><\/i> Heart Attack History?\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"q-inputs\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"heart-attack\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"heart-attack\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"heart-attack\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"heart-attack-desc\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"If yes, please provide details\" value=\"\" type=\"text\" name=\"heart-attack-desc\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<div class=\"field-wrap full-width question-box\">\n\t\t\t\t<div class=\"q-title\">\n\t\t\t\t\t<p><i class=\"fa-solid fa-x-ray text-gray\"><\/i> Do you have any metal implants\/devices?\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"q-inputs\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"metal-implants\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"metal-implants\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"metal-implants\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"metal-implants-desc\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"If yes, please provide details\" value=\"\" type=\"text\" name=\"metal-implants-desc\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<div class=\"field-wrap full-width input-icon\">\n\t\t\t\t<p><i class=\"fa-solid fa-notes-medical\"><\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-illness\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Other serious illness that you have had\" value=\"\" type=\"text\" name=\"other-illness\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"field-wrap question-box\">\n\t\t\t\t<div class=\"q-title\">\n\t\t\t\t\t<p><i class=\"fa-solid fa-smoking\"><\/i> Do you smoke?\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"q-inputs\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"smoke\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"smoke\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"smoke\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"smoke-amount\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"How much?\" value=\"\" type=\"text\" name=\"smoke-amount\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<div class=\"field-wrap question-box\">\n\t\t\t\t<div class=\"q-title\">\n\t\t\t\t\t<p><i class=\"fa-solid fa-wine-glass\"><\/i> Drink alcohol?\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"q-inputs\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"alcohol\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"alcohol\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"alcohol\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"alcohol-amount\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"How much?\" value=\"\" type=\"text\" name=\"alcohol-amount\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<div class=\"field-wrap full-width input-icon textarea-icon\">\n\t\t\t\t<p><i class=\"fa-solid fa-pills\"><\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"meds-regular\"><textarea cols=\"40\" rows=\"3\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Please list the medications you take regularly\" name=\"meds-regular\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"field-wrap full-width input-icon textarea-icon\">\n\t\t\t\t<p><i class=\"fa-solid fa-prescription-bottle-medical\"><\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"meds-last-month\"><textarea cols=\"40\" rows=\"3\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Please list the medications you have taken in the last month\" name=\"meds-last-month\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"field-wrap full-width input-icon textarea-icon\">\n\t\t\t\t<p><i class=\"fa-solid fa-users-medical\"><\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"family-disease\"><textarea cols=\"40\" rows=\"3\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Do you know of any blood relative who has or had any chronic or congenital disease? (If yes, please provide details)\" name=\"family-disease\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"field-wrap full-width input-icon textarea-icon\">\n\t\t\t\t<p><i class=\"fa-solid fa-droplet\"><\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"blood-transfusion\"><textarea cols=\"40\" rows=\"3\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Have you ever had a blood transfusion? (If yes, when and why?)\" name=\"blood-transfusion\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"field-wrap full-width input-icon\">\n\t\t\t\t<p><i class=\"fa-solid fa-weight-scale\"><\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"weight-loss\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Have you lost significant amount of weight in the last year?\" value=\"\" type=\"text\" name=\"weight-loss\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"field-wrap full-width input-icon\">\n\t\t\t\t<p><i class=\"fa-solid fa-staff-snake\"><\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dvt-history\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Do you have any history of deep vein thrombosis?\" value=\"\" type=\"text\" name=\"dvt-history\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"field-wrap full-width input-icon textarea-icon\">\n\t\t\t\t<p><i class=\"fa-solid fa-head-side-cough\"><\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"allergies\"><textarea cols=\"40\" rows=\"3\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Do you have any allergy? (Give details)\" name=\"allergies\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-section\">\n\t\t<h3 class=\"section-title\"><i class=\"fa-solid fa-user-doctor\"><\/i> PAST SURGERIES & ANAMNESIS\n\t\t<\/h3>\n\t\t<div class=\"grid-row\">\n\t\t\t<div class=\"field-wrap full-width input-icon\">\n\t\t\t\t<p><i class=\"fa-solid fa-procedures\"><\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"past-surgeries\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"List your past surgeries\" value=\"\" type=\"text\" name=\"past-surgeries\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"field-wrap full-width input-icon\">\n\t\t\t\t<p><i class=\"fa-regular fa-hospital\"><\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hospital\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Hospital\" value=\"\" type=\"text\" name=\"hospital\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"field-wrap full-width question-box\">\n\t\t\t\t<div class=\"q-title\">\n\t\t\t\t\t<p><i class=\"fa-solid fa-mask-ventilator\"><\/i> Bad reactions to anesthesia?\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"q-inputs\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"anesthesia-react\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"anesthesia-react\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"anesthesia-react\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"anesthesia-list\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"List if any\" value=\"\" type=\"text\" name=\"anesthesia-list\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-section women-only-bg\">\n\t\t<h3 class=\"section-title pink-text\"><i class=\"fa-solid fa-venus\"><\/i> WOMEN ONLY\n\t\t<\/h3>\n\t\t<div class=\"grid-row\">\n\t\t\t<div class=\"field-wrap question-box\">\n\t\t\t\t<div class=\"q-title\">\n\t\t\t\t\t<p>Pregnant?\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"pregnant\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"pregnant\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"pregnant\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"field-wrap input-icon\">\n\t\t\t\t<p><i class=\"fa-solid fa-baby\"><\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pregnancies\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Number of Pregnancies\" value=\"\" type=\"text\" name=\"pregnancies\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"field-wrap question-box\">\n\t\t\t\t<div class=\"q-title\">\n\t\t\t\t\t<p>Regular periods?\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"periods\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"periods\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"periods\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"field-wrap input-icon\">\n\t\t\t\t<p><i class=\"fa-regular fa-calendar-check\"><\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"last-period\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Last period date\" value=\"\" type=\"text\" name=\"last-period\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"field-wrap full-width input-icon\">\n\t\t\t\t<p><i class=\"fa-solid fa-capsules\"><\/i><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"birth-control\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Do you take birth control pills? (If yes, please list)\" value=\"\" type=\"text\" name=\"birth-control\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-section\">\n\t\t<h3 class=\"section-title\"><i class=\"fa-solid fa-bed\"><\/i> SLEEP APNEA SYMPTOMS\n\t\t<\/h3>\n\t\t<div class=\"medical-grid\">\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\"><i class=\"fa-solid fa-face-tired text-gray\"><\/i> Tired upon waking<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"sleep-tired\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"sleep-tired\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"sleep-tired\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\"><i class=\"fa-solid fa-eye text-gray\"><\/i> Trouble staying asleep<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"sleep-stay\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"sleep-stay\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"sleep-stay\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\"><i class=\"fa-solid fa-volume-high text-gray\"><\/i> Told that I snore<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"sleep-snore\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"sleep-snore\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"sleep-snore\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"medical-item\">\n\t\t\t\t<p><span class=\"m-title\"><i class=\"fa-solid fa-bed-pulse text-gray\"><\/i> Arms\/legs jerk<\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"sleep-jerk\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"sleep-jerk\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"sleep-jerk\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"submit-container\">\n\t\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner submit-btn\" type=\"submit\" value=\"Submit Medical Form\" \/>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<style>\n\/* GENEL AYARLAR *\/\n#patient-form { max-width: 1000px; margin: 0 auto; background: #ffffff; padding: 20px; font-family: 'Inter', -apple-system, sans-serif; color: #333; box-sizing: border-box; }\n#patient-form * { box-sizing: border-box; }\n#patient-form .form-section { margin-bottom: 40px; padding: 25px; border: 1px solid #eaeaea; border-radius: 12px; background: #fdfdfd; box-shadow: 0 2px 8px rgba(0,0,0,0.02); }\n#patient-form .section-title { font-size: 20px; font-weight: 700; color: #1f2937; margin-bottom: 20px; border-bottom: 3px solid #10b981; display: inline-block; padding-bottom: 5px; }\n#patient-form .section-title i { margin-right: 8px; color: #10b981; }\n#patient-form .section-subtitle { font-size: 13px; color: #6b7280; margin-top: -15px; margin-bottom: 20px; display: block; }\n#patient-form .grid-row { display: grid; grid-template-columns: repeat(2, 1fr); gap: 18px; }\n#patient-form .full-width { grid-column: span 2; }\n#patient-form .medical-grid { display: grid; grid-template-columns: repeat(3, 1fr); gap: 15px; }\n\n\/* HASTALIK KUTULARI *\/\n#patient-form .medical-item { \n display: flex; flex-direction: column; background: #fff; padding: 15px; \n border: 1px solid #e5e7eb; border-radius: 8px; font-size: 14px; gap: 12px;\n}\n#patient-form .m-title { \n display: flex; align-items: flex-start; font-weight: 600; color: #374151; width: 100%; line-height: 1.4; \n}\n#patient-form .m-title i { width: 20px; text-align: center; margin-right: 8px; font-size: 16px; flex-shrink: 0; margin-top: 2px; }\n\n\/* =========================================================\n SADECE CSS: BAS\u0130T VE GARANT\u0130L\u0130 RADYO BUTONU + HAP (PILL) TASARIMI\n ========================================================= *\/\n\n\/* Teman\u0131n Sahte Elementlerini Tamamen Gizle *\/\n#patient-form .wpcf7-list-item label::before, \n#patient-form .wpcf7-list-item label::after, \n#patient-form .wpcf7-list-item-label::before, \n#patient-form .wpcf7-list-item-label::after { \n display: none !important; content: none !important; \n}\n\n\/* Yan yana hizalama ve bo\u015fluklar *\/\n#patient-form .wpcf7-radio { display: flex !important; flex-wrap: wrap !important; gap: 10px !important; margin: 0 !important; width: 100% !important; }\n#patient-form .wpcf7-list-item { margin: 0 !important; padding: 0 !important; display: inline-block !important; }\n\n\/* Label (T\u0131klama Alan\u0131 ve Hap G\u00f6r\u00fcn\u00fcm\u00fc) *\/\n#patient-form .wpcf7-list-item label { \n display: inline-flex !important; \n align-items: center !important; \n justify-content: center !important; \n background-color: #f3f4f6 !important; \/* A\u00e7\u0131k gri arka plan *\/\n padding: 8px 16px !important; \/* T\u0131klama alan\u0131, mobilde rahat\u00e7a dokunulacak boyut *\/\n border-radius: 30px !important; \/* Hap g\u00f6r\u00fcn\u00fcm\u00fc *\/\n cursor: pointer !important; \n margin: 0 !important; \n transition: background-color 0.2s ease !important;\n}\n\n#patient-form .wpcf7-list-item label:hover {\n background-color: #e5e7eb !important; \n}\n\n\/* Taray\u0131c\u0131n\u0131n Orijinal Radyo Butonu (G\u00f6r\u00fcn\u00fcr, T\u0131klanabilir, Standart) *\/\n#patient-form .wpcf7-list-item input[type=\"radio\"] { \n display: inline-block !important; \n appearance: radio !important; \n -webkit-appearance: radio !important; \n -moz-appearance: radio !important; \n width: 16px !important; \n height: 16px !important; \n margin: 0 8px 0 0 !important; \/* Yaz\u0131 ile yuvarlak aras\u0131ndaki bo\u015fluk *\/\n opacity: 1 !important; \/* G\u00f6r\u00fcn\u00fcr *\/\n position: static !important; \n cursor: pointer !important;\n}\n\n\/* \"Yes\/No\" Yaz\u0131s\u0131n\u0131n Stili *\/\n#patient-form .wpcf7-list-item-label {\n color: #4b5563 !important;\n font-size: 14px !important;\n font-weight: 600 !important;\n}\n\n\/* SADECE CSS \u0130LE SE\u00c7\u0130L\u0130 DURUM: Modern CSS :has() se\u00e7icisi *\/\n\/* Radyo butonu se\u00e7ildi\u011finde kapsay\u0131c\u0131 label'\u0131n arka plan\u0131n\u0131 hafif de\u011fi\u015ftirir *\/\n#patient-form .wpcf7-list-item label:has(input[type=\"radio\"]:checked) {\n background-color: #e5e7eb !important;\n box-shadow: 0 1px 3px rgba(0,0,0,0.05) !important;\n}\n\n\/* ========================================================= *\/\n\n\/* D\u0130\u011eER \u0130NPUTLAR VE TASARIMLAR *\/\n#patient-form .input-icon { position: relative; width: 100%; }\n#patient-form .input-icon > i { position: absolute; left: 16px; top: 16px; color: #9ca3af; font-size: 16px; z-index: 2; }\n#patient-form .textarea-icon > i { top: 16px; }\n#patient-form .input-icon input, #patient-form .input-icon textarea { padding-left: 45px !important; }\n#patient-form input[type=\"text\"], #patient-form input[type=\"email\"], #patient-form input[type=\"tel\"], #patient-form input[type=\"date\"], #patient-form textarea { width: 100%; padding: 14px 16px; border: 1px solid #d1d5db; border-radius: 8px; font-size: 14px; background: #ffffff; transition: 0.3s; }\n#patient-form input:focus, #patient-form textarea:focus { border-color: #10b981; outline: none; box-shadow: 0 0 0 3px rgba(16,185,129,0.15); }\n#patient-form .question-box { background: #f9fafb; padding: 16px; border-radius: 8px; border: 1px solid #e5e7eb; display: flex; flex-direction: column; justify-content: center; gap: 12px; }\n#patient-form .q-title { font-weight: 600; font-size: 14px; color: #4b5563; display: flex; align-items: flex-start; }\n#patient-form .q-title i { margin-right: 6px; color: #6b7280; flex-shrink: 0; margin-top: 3px; }\n#patient-form .q-inputs { display: flex; flex-wrap: wrap; gap: 10px; align-items: center; }\n#patient-form .q-inputs input[type=\"text\"] { padding: 8px 12px; height: 38px; flex-grow: 1; }\n\n#patient-form .women-only-bg { border-color: #fce7f3; background: #fdf2f8; }\n#patient-form .pink-text { color: #db2777; border-bottom-color: #db2777; }\n#patient-form .pink-text i { color: #db2777; }\n#patient-form .text-red { color: #ef4444; } #patient-form .text-blue { color: #3b82f6; } #patient-form .text-purple { color: #8b5cf6; } #patient-form .text-gray { color: #6b7280; } #patient-form .text-green { color: #10b981; }\n\n#patient-form .submit-container { text-align: center; margin-top: 20px; }\n#patient-form .submit-btn { background: #065f46; color: #fff; padding: 16px 60px; border: none; border-radius: 30px; font-size: 16px; font-weight: 600; cursor: pointer; transition: 0.3s; width: 100%; max-width: 300px; }\n#patient-form .submit-btn:hover { background: #10b981; transform: translateY(-2px); box-shadow: 0 4px 12px rgba(16,185,129,0.3); }\n\n\/* MOB\u0130L UYUM *\/\n@media (max-width: 992px) { #patient-form .medical-grid { grid-template-columns: repeat(2, 1fr); } }\n@media (max-width: 600px) { \n #patient-form .grid-row, #patient-form .medical-grid { grid-template-columns: 1fr; }\n #patient-form .full-width { grid-column: span 1; }\n #patient-form { padding: 10px; }\n #patient-form .form-section { padding: 15px; }\n #patient-form .q-inputs { flex-direction: column; align-items: flex-start; }\n #patient-form .q-inputs input[type=\"text\"] { width: 100%; }\n}\n#patient-form .mt-20 { margin-top: 20px; }\n<\/style><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"sharing-default-minimal post-bottom\"><div class=\"nectar-social default\" data-position=\"\" data-rm-love=\"0\" data-color-override=\"override\"><div class=\"nectar-social-inner\"><a href=\"#\" class=\"nectar-love\" id=\"nectar-love-1865\" title=\"Love this\"> <i class=\"icon-salient-heart-2\"><\/i><span class=\"love-text\">Love<\/span><span class=\"total_loves\"><span class=\"nectar-love-count\">0<\/span><\/span><\/a><a class='facebook-share nectar-sharing' href='#' title='Share this'> <i class='fa fa-facebook'><\/i> <span class='social-text'>Share<\/span> <\/a><a class='twitter-share nectar-sharing' href='#' title='Share this'> <i class='fa icon-salient-x-twitter'><\/i> <span class='social-text'>Share<\/span> <\/a><a class='linkedin-share nectar-sharing' href='#' title='Share this'> <i class='fa fa-linkedin'><\/i> <span class='social-text'>Share<\/span> <\/a><a class='pinterest-share nectar-sharing' href='#' title='Pin this'> <i class='fa fa-pinterest'><\/i> <span class='social-text'>Pin<\/span> <\/a><\/div><\/div><\/div>","protected":false},"excerpt":{"rendered":"<p>Love0 Share Share Share Pin<\/p>","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"_angie_page":false,"footnotes":""},"class_list":["post-1865","page","type-page","status-publish","hentry"],"acf":[],"_hostinger_reach_plugin_has_subscription_block":false,"_hostinger_reach_plugin_is_elementor":false,"_links":{"self":[{"href":"https:\/\/revitalizeinturkey.com\/de\/wp-json\/wp\/v2\/pages\/1865","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/revitalizeinturkey.com\/de\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/revitalizeinturkey.com\/de\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/revitalizeinturkey.com\/de\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/revitalizeinturkey.com\/de\/wp-json\/wp\/v2\/comments?post=1865"}],"version-history":[{"count":4,"href":"https:\/\/revitalizeinturkey.com\/de\/wp-json\/wp\/v2\/pages\/1865\/revisions"}],"predecessor-version":[{"id":61814,"href":"https:\/\/revitalizeinturkey.com\/de\/wp-json\/wp\/v2\/pages\/1865\/revisions\/61814"}],"wp:attachment":[{"href":"https:\/\/revitalizeinturkey.com\/de\/wp-json\/wp\/v2\/media?parent=1865"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}