{"id":29,"date":"2020-06-24T17:34:29","date_gmt":"2020-06-24T17:34:29","guid":{"rendered":"http:\/\/www.arrantsurgical.com\/?page_id=29"},"modified":"2020-06-24T17:34:30","modified_gmt":"2020-06-24T17:34:30","slug":"new-patient-form","status":"publish","type":"page","link":"https:\/\/www.arrantsurgical.com\/index.php\/new-patient-form\/","title":{"rendered":"New Patient Form"},"content":{"rendered":"\n<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-27\"><form id=\"wpforms-form-27\" class=\"wpforms-validate wpforms-form\" data-formid=\"27\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/29\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-27-field_2-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_2\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-27-field_2\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][2][first]\" required><label for=\"wpforms-27-field_2\" class=\"wpforms-field-sublabel after \">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-27-field_2-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][2][last]\" required><label for=\"wpforms-27-field_2-last\" class=\"wpforms-field-sublabel after \">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-27-field_48-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"48\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_48\">Sex<\/label><ul id=\"wpforms-27-field_48\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_48_1\" name=\"wpforms[fields][48][]\" value=\"Male\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_48_1\">Male<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_48_2\" name=\"wpforms[fields][48][]\" value=\"Female\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_48_2\">Female<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_48_3\" name=\"wpforms[fields][48][]\" value=\"Other\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_48_3\">Other<\/label><\/li><\/ul><\/div><div id=\"wpforms-27-field_49-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"49\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_49\">Height<\/label><input type=\"text\" id=\"wpforms-27-field_49\" class=\"wpforms-field-medium\" name=\"wpforms[fields][49]\" ><\/div><div id=\"wpforms-27-field_50-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"50\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_50\">Weight<\/label><input type=\"text\" id=\"wpforms-27-field_50\" class=\"wpforms-field-medium\" name=\"wpforms[fields][50]\" ><\/div><div id=\"wpforms-27-field_17-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_17\">Address<\/label><input type=\"text\" id=\"wpforms-27-field_17\" class=\"wpforms-field-medium\" name=\"wpforms[fields][17]\" ><\/div><div id=\"wpforms-27-field_18-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_18\">City<\/label><input type=\"text\" id=\"wpforms-27-field_18\" class=\"wpforms-field-medium\" name=\"wpforms[fields][18]\" ><\/div><div id=\"wpforms-27-field_20-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_20\">State<\/label><input type=\"text\" id=\"wpforms-27-field_20\" class=\"wpforms-field-small\" name=\"wpforms[fields][20]\" ><\/div><div id=\"wpforms-27-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_8\">Zip Code<\/label><input type=\"text\" id=\"wpforms-27-field_8\" class=\"wpforms-field-small\" name=\"wpforms[fields][8]\" ><\/div><div id=\"wpforms-27-field_3-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_3\">Email Address <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-27-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" required><\/div><div id=\"wpforms-27-field_21-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_21\">Primary Medical Doctor<\/label><input type=\"text\" id=\"wpforms-27-field_21\" class=\"wpforms-field-medium\" name=\"wpforms[fields][21]\" ><\/div><div id=\"wpforms-27-field_22-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_22\">Referring Surgeon<\/label><input type=\"text\" id=\"wpforms-27-field_22\" class=\"wpforms-field-medium\" name=\"wpforms[fields][22]\" ><\/div><div id=\"wpforms-27-field_4-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_4\">Chronic Medical Conditions<\/label><ul id=\"wpforms-27-field_4\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_4_1\" name=\"wpforms[fields][4][]\" value=\"No Medical Problems\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_4_1\">No Medical Problems<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_4_2\" name=\"wpforms[fields][4][]\" value=\"Diabetes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_4_2\">Diabetes<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_4_3\" name=\"wpforms[fields][4][]\" value=\"Heart Disease\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_4_3\">Heart Disease<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_4_13\" name=\"wpforms[fields][4][]\" value=\"Heart Attack\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_4_13\">Heart Attack<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_4_10\" name=\"wpforms[fields][4][]\" value=\"Atrial Fibrillation\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_4_10\">Atrial Fibrillation<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_4_4\" name=\"wpforms[fields][4][]\" value=\"High Blood Pressure\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_4_4\">High Blood Pressure<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_4_11\" name=\"wpforms[fields][4][]\" value=\"Blood Clots (DVT\/Pulmonary Embolus)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_4_11\">Blood Clots (DVT\/Pulmonary Embolus)<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_4_5\" name=\"wpforms[fields][4][]\" value=\"Cancer\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_4_5\">Cancer<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_4_6\" name=\"wpforms[fields][4][]\" value=\"Stroke\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_4_6\">Stroke<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_4_7\" name=\"wpforms[fields][4][]\" value=\"Thyroid Problems\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_4_7\">Thyroid Problems<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_4_8\" name=\"wpforms[fields][4][]\" value=\"Depression\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_4_8\">Depression<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_4_9\" name=\"wpforms[fields][4][]\" value=\"Anxiety\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_4_9\">Anxiety<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_4_12\" name=\"wpforms[fields][4][]\" value=\"Constipation\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_4_12\">Constipation<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_4_14\" name=\"wpforms[fields][4][]\" value=\"Acid Reflux\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_4_14\">Acid Reflux<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_4_15\" name=\"wpforms[fields][4][]\" value=\"Stomach Ulcer\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_4_15\">Stomach Ulcer<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_4_16\" name=\"wpforms[fields][4][]\" value=\"Diverticulitis\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_4_16\">Diverticulitis<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_4_17\" name=\"wpforms[fields][4][]\" value=\"Kidney Problems\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_4_17\">Kidney Problems<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_4_18\" name=\"wpforms[fields][4][]\" value=\"Skin Condition\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_4_18\">Skin Condition<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_4_19\" name=\"wpforms[fields][4][]\" value=\"Asthma\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_4_19\">Asthma<\/label><\/li><li class=\"choice-20 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_4_20\" name=\"wpforms[fields][4][]\" value=\"COPD \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_4_20\">COPD <\/label><\/li><li class=\"choice-21 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_4_21\" name=\"wpforms[fields][4][]\" value=\"Sleep Apnea\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_4_21\">Sleep Apnea<\/label><\/li><\/ul><\/div><div id=\"wpforms-27-field_34-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_34\">Other Medical Conditions Not Listed Above or Description of Type of Cancer\/Heart Disease\/Kidney Problems\/etc.<\/label><textarea id=\"wpforms-27-field_34\" class=\"wpforms-field-medium\" name=\"wpforms[fields][34]\" ><\/textarea><\/div><div id=\"wpforms-27-field_31-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_31\">All Surgeries with Date (i.e. Appendectomy - 6\/2012)<\/label><textarea id=\"wpforms-27-field_31\" class=\"wpforms-field-medium\" name=\"wpforms[fields][31]\" ><\/textarea><\/div><div id=\"wpforms-27-field_32-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_32\">Mother&#039;s History<\/label><ul id=\"wpforms-27-field_32\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-27-field_32_1\" name=\"wpforms[fields][32]\" value=\"Living\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_32_1\">Living<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-27-field_32_2\" name=\"wpforms[fields][32]\" value=\"Deceased\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_32_2\">Deceased<\/label><\/li><\/ul><\/div><div id=\"wpforms-27-field_33-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_33\">Mother&#039;s Age &amp; Medical Problems<\/label><textarea id=\"wpforms-27-field_33\" class=\"wpforms-field-medium\" name=\"wpforms[fields][33]\" ><\/textarea><\/div><div id=\"wpforms-27-field_35-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"35\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_35\">Fathers History<\/label><ul id=\"wpforms-27-field_35\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_35_1\" name=\"wpforms[fields][35][]\" value=\"Living\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_35_1\">Living<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_35_2\" name=\"wpforms[fields][35][]\" value=\"Deceased\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_35_2\">Deceased<\/label><\/li><\/ul><\/div><div id=\"wpforms-27-field_36-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"36\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_36\">Father&#039;s Age &amp; Medical Problems<\/label><textarea id=\"wpforms-27-field_36\" class=\"wpforms-field-medium\" name=\"wpforms[fields][36]\" ><\/textarea><\/div><div id=\"wpforms-27-field_38-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"38\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_38\">Sisters: Number, Age, Medical Problems (i.e. 2 Sisters Age 34 - Diabetes; Age 45 - Heart Attack)<\/label><textarea id=\"wpforms-27-field_38\" class=\"wpforms-field-medium\" name=\"wpforms[fields][38]\" ><\/textarea><\/div><div id=\"wpforms-27-field_39-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"39\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_39\">Brothers: Number, Age, Medical Problems (i.e. 1 Brother Age 55 - High Blood Pressure &amp; Prostate Cancer)<\/label><textarea id=\"wpforms-27-field_39\" class=\"wpforms-field-medium\" name=\"wpforms[fields][39]\" ><\/textarea><\/div><div id=\"wpforms-27-field_40-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"40\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_40\">Occupation<\/label><input type=\"text\" id=\"wpforms-27-field_40\" class=\"wpforms-field-medium\" name=\"wpforms[fields][40]\" ><\/div><div id=\"wpforms-27-field_47-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"47\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_47\">Employment Status<\/label><ul id=\"wpforms-27-field_47\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-27-field_47_1\" name=\"wpforms[fields][47]\" value=\"Employed: Full Time\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_47_1\">Employed: Full Time<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-27-field_47_2\" name=\"wpforms[fields][47]\" value=\"Employed: Part Time\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_47_2\">Employed: Part Time<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-27-field_47_3\" name=\"wpforms[fields][47]\" value=\"Unemployed\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_47_3\">Unemployed<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-27-field_47_4\" name=\"wpforms[fields][47]\" value=\"Diasabled\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_47_4\">Diasabled<\/label><\/li><\/ul><\/div><div id=\"wpforms-27-field_41-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"41\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_41\">Marital Status<\/label><ul id=\"wpforms-27-field_41\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_41_1\" name=\"wpforms[fields][41][]\" value=\"Single\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_41_1\">Single<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_41_2\" name=\"wpforms[fields][41][]\" value=\"Married\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_41_2\">Married<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_41_5\" name=\"wpforms[fields][41][]\" value=\"Seperated\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_41_5\">Seperated<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_41_3\" name=\"wpforms[fields][41][]\" value=\"Divorced\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_41_3\">Divorced<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_41_4\" name=\"wpforms[fields][41][]\" value=\"Widowed\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_41_4\">Widowed<\/label><\/li><\/ul><\/div><div id=\"wpforms-27-field_42-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_42\"># of Children<\/label><input type=\"text\" id=\"wpforms-27-field_42\" class=\"wpforms-field-medium\" name=\"wpforms[fields][42]\" ><\/div><div id=\"wpforms-27-field_51-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"51\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_51\">Tobacco<\/label><ul id=\"wpforms-27-field_51\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_51_1\" name=\"wpforms[fields][51][]\" value=\"Never Smoked\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_51_1\">Never Smoked<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_51_2\" name=\"wpforms[fields][51][]\" value=\"1\/2 Packs Per Day\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_51_2\">1\/2 Packs Per Day<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_51_3\" name=\"wpforms[fields][51][]\" value=\"1 Pack Per Day\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_51_3\">1 Pack Per Day<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_51_4\" name=\"wpforms[fields][51][]\" value=\"2 Packs Per Day\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_51_4\">2 Packs Per Day<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_51_5\" name=\"wpforms[fields][51][]\" value=\"3 Packs Per Day\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_51_5\">3 Packs Per Day<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_51_6\" name=\"wpforms[fields][51][]\" value=\"Previous Smoker\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_51_6\">Previous Smoker<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_51_7\" name=\"wpforms[fields][51][]\" value=\"Cigars\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_51_7\">Cigars<\/label><\/li><\/ul><\/div><div id=\"wpforms-27-field_46-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"46\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_46\">If Previous Smoker Date Quit and Amount Previously Smoked (i.e. Quit in 2012 with a 1 Pack Per Day History)<\/label><textarea id=\"wpforms-27-field_46\" class=\"wpforms-field-medium\" name=\"wpforms[fields][46]\" ><\/textarea><\/div><div id=\"wpforms-27-field_44-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"44\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_44\">Alcohol: Amount, Type, Frequency (i.e. 2 Glasses of Wine Daily)<\/label><textarea id=\"wpforms-27-field_44\" class=\"wpforms-field-medium\" name=\"wpforms[fields][44]\" ><\/textarea><\/div><div id=\"wpforms-27-field_45-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"45\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_45\">Drug Use (Current or Previous)<\/label><ul id=\"wpforms-27-field_45\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_45_1\" name=\"wpforms[fields][45][]\" value=\"Marijuana\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_45_1\">Marijuana<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_45_2\" name=\"wpforms[fields][45][]\" value=\"Cocaine\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_45_2\">Cocaine<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-27-field_45_3\" name=\"wpforms[fields][45][]\" value=\"Heroin\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-27-field_45_3\">Heroin<\/label><\/li><\/ul><\/div><div id=\"wpforms-27-field_23-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_23\">Medications, Dosages, &amp; How Taken (i.e. Lasix 20mg twice a day)<\/label><textarea id=\"wpforms-27-field_23\" class=\"wpforms-field-medium\" name=\"wpforms[fields][23]\" ><\/textarea><\/div><div id=\"wpforms-27-field_25-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-27-field_25\">Allergies &amp; Reaction (i.e PCN - Rash)<\/label><textarea id=\"wpforms-27-field_25\" class=\"wpforms-field-medium\" name=\"wpforms[fields][25]\" ><\/textarea><\/div><\/div><div class=\"wpforms-field wpforms-field-hp\"><label for=\"wpforms-27-field-hp\" class=\"wpforms-field-label\">Email<\/label><input type=\"text\" name=\"wpforms[hp]\" id=\"wpforms-27-field-hp\" class=\"wpforms-field-medium\"><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"27\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"1\"><button type=\"submit\" name=\"wpforms[submit]\" class=\"wpforms-submit \" id=\"wpforms-submit-27\" value=\"wpforms-submit\" aria-live=\"assertive\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\">Submit<\/button><\/div><\/form><\/div>  <!-- .wpforms-container 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