{"id":62,"date":"2020-12-22T19:46:30","date_gmt":"2020-12-22T19:46:30","guid":{"rendered":"http:\/\/www.arrantsurgical.com\/?page_id=62"},"modified":"2020-12-22T19:46:30","modified_gmt":"2020-12-22T19:46:30","slug":"review-of-systems","status":"publish","type":"page","link":"https:\/\/www.arrantsurgical.com\/index.php\/review-of-systems\/","title":{"rendered":"Review of Systems"},"content":{"rendered":"\n<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-59\"><form id=\"wpforms-form-59\" class=\"wpforms-validate wpforms-form\" data-formid=\"59\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/62\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-59-field_58-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"58\"><label class=\"wpforms-field-label\" for=\"wpforms-59-field_58\">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-59-field_58\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][58][first]\" required><label for=\"wpforms-59-field_58\" class=\"wpforms-field-sublabel after \">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-59-field_58-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][58][last]\" required><label for=\"wpforms-59-field_58-last\" class=\"wpforms-field-sublabel after \">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-59-field_45-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"45\"><label class=\"wpforms-field-label\" for=\"wpforms-59-field_45\">Constitutional Symptoms<\/label><ul id=\"wpforms-59-field_45\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_45_1\" name=\"wpforms[fields][45][]\" value=\"Fever\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_45_1\">Fever<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_45_2\" name=\"wpforms[fields][45][]\" value=\"Chills\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_45_2\">Chills<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_45_3\" name=\"wpforms[fields][45][]\" value=\"Abnormal Weight Gain\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_45_3\">Abnormal Weight Gain<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_45_4\" name=\"wpforms[fields][45][]\" value=\"Abnormal Weight Loss\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_45_4\">Abnormal Weight Loss<\/label><\/li><\/ul><\/div><div id=\"wpforms-59-field_31-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-59-field_31\">Other\/Description:<\/label><input type=\"text\" id=\"wpforms-59-field_31\" class=\"wpforms-field-medium\" name=\"wpforms[fields][31]\" ><\/div><div id=\"wpforms-59-field_46-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"46\"><label class=\"wpforms-field-label\" for=\"wpforms-59-field_46\">Eyes<\/label><ul id=\"wpforms-59-field_46\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_46_1\" name=\"wpforms[fields][46][]\" value=\"Blurred Vision\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_46_1\">Blurred Vision<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_46_2\" name=\"wpforms[fields][46][]\" value=\"Double Vision\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_46_2\">Double Vision<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_46_3\" name=\"wpforms[fields][46][]\" value=\"Eye Pain\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_46_3\">Eye Pain<\/label><\/li><\/ul><\/div><div id=\"wpforms-59-field_32-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-59-field_32\">Other\/Description:<\/label><input type=\"text\" id=\"wpforms-59-field_32\" class=\"wpforms-field-medium\" name=\"wpforms[fields][32]\" ><\/div><div id=\"wpforms-59-field_47-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"47\"><label class=\"wpforms-field-label\" for=\"wpforms-59-field_47\">Allergic\/Immunologic<\/label><ul id=\"wpforms-59-field_47\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_47_1\" name=\"wpforms[fields][47][]\" value=\"Hay Fever\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_47_1\">Hay Fever<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_47_2\" name=\"wpforms[fields][47][]\" value=\"Drug Allergies\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_47_2\">Drug Allergies<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_47_3\" name=\"wpforms[fields][47][]\" value=\"Food Allergies\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_47_3\">Food Allergies<\/label><\/li><\/ul><\/div><div id=\"wpforms-59-field_33-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-59-field_33\">Other\/Description:<\/label><input type=\"text\" id=\"wpforms-59-field_33\" class=\"wpforms-field-medium\" name=\"wpforms[fields][33]\" ><\/div><div id=\"wpforms-59-field_48-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"48\"><label class=\"wpforms-field-label\" for=\"wpforms-59-field_48\">Neurological<\/label><ul id=\"wpforms-59-field_48\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_48_1\" name=\"wpforms[fields][48][]\" value=\"Seizures\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_48_1\">Seizures<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_48_2\" name=\"wpforms[fields][48][]\" value=\"Tremors\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_48_2\">Tremors<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_48_3\" name=\"wpforms[fields][48][]\" value=\"Dizzy Spells\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_48_3\">Dizzy Spells<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_48_4\" name=\"wpforms[fields][48][]\" value=\"Numbness\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_48_4\">Numbness<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_48_5\" name=\"wpforms[fields][48][]\" value=\"Tingling\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_48_5\">Tingling<\/label><\/li><\/ul><\/div><div id=\"wpforms-59-field_34-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-59-field_34\">Other\/Description:<\/label><input type=\"text\" id=\"wpforms-59-field_34\" class=\"wpforms-field-medium\" name=\"wpforms[fields][34]\" ><\/div><div id=\"wpforms-59-field_49-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"49\"><label class=\"wpforms-field-label\" for=\"wpforms-59-field_49\">Genitourinary<\/label><ul id=\"wpforms-59-field_49\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_49_1\" name=\"wpforms[fields][49][]\" value=\"Painful Urination\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_49_1\">Painful Urination<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_49_2\" name=\"wpforms[fields][49][]\" value=\"Urinary Frequency\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_49_2\">Urinary Frequency<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_49_3\" name=\"wpforms[fields][49][]\" value=\"Scant Urination\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_49_3\">Scant Urination<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_49_5\" name=\"wpforms[fields][49][]\" value=\"Frequent Urinary Tract Infections\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_49_5\">Frequent Urinary Tract Infections<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_49_4\" name=\"wpforms[fields][49][]\" value=\"Prostate Problems\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_49_4\">Prostate Problems<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_49_6\" name=\"wpforms[fields][49][]\" value=\"Sexual Dysfunction\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_49_6\">Sexual Dysfunction<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_49_7\" name=\"wpforms[fields][49][]\" value=\"Urinary Incontinence (Leakage)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_49_7\">Urinary Incontinence (Leakage)<\/label><\/li><\/ul><\/div><div id=\"wpforms-59-field_35-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"35\"><label class=\"wpforms-field-label\" for=\"wpforms-59-field_35\">Other\/Description:<\/label><input type=\"text\" id=\"wpforms-59-field_35\" class=\"wpforms-field-medium\" name=\"wpforms[fields][35]\" ><\/div><div id=\"wpforms-59-field_50-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"50\"><label class=\"wpforms-field-label\" for=\"wpforms-59-field_50\">Hematologic\/Lymphatic<\/label><ul id=\"wpforms-59-field_50\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_50_1\" name=\"wpforms[fields][50][]\" value=\"Swollen\/Enlarged Lymph Nodes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_50_1\">Swollen\/Enlarged Lymph Nodes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_50_2\" name=\"wpforms[fields][50][]\" value=\"Excessive Bleeding\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_50_2\">Excessive Bleeding<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_50_3\" name=\"wpforms[fields][50][]\" value=\"Blood Clot History\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_50_3\">Blood Clot History<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_50_4\" name=\"wpforms[fields][50][]\" value=\"Religious Objection to Blood Transfusion\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_50_4\">Religious Objection to Blood Transfusion<\/label><\/li><\/ul><\/div><div id=\"wpforms-59-field_36-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"36\"><label class=\"wpforms-field-label\" for=\"wpforms-59-field_36\">Other\/Description:<\/label><input type=\"text\" id=\"wpforms-59-field_36\" class=\"wpforms-field-medium\" name=\"wpforms[fields][36]\" ><\/div><div id=\"wpforms-59-field_51-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"51\"><label class=\"wpforms-field-label\" for=\"wpforms-59-field_51\">Digestive System<\/label><ul id=\"wpforms-59-field_51\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_51_1\" name=\"wpforms[fields][51][]\" value=\"Heartburn\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_51_1\">Heartburn<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_51_2\" name=\"wpforms[fields][51][]\" value=\"Diarrhea\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_51_2\">Diarrhea<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_51_3\" name=\"wpforms[fields][51][]\" value=\"Constipation\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_51_3\">Constipation<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_51_4\" name=\"wpforms[fields][51][]\" value=\"Food Intolerance\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_51_4\">Food Intolerance<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_51_5\" name=\"wpforms[fields][51][]\" value=\"Nausea\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_51_5\">Nausea<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_51_6\" name=\"wpforms[fields][51][]\" value=\"Belching\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_51_6\">Belching<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_51_7\" name=\"wpforms[fields][51][]\" value=\"Bloating\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_51_7\">Bloating<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_51_8\" name=\"wpforms[fields][51][]\" value=\"Digestive Pain\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_51_8\">Digestive Pain<\/label><\/li><\/ul><\/div><div id=\"wpforms-59-field_37-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"37\"><label class=\"wpforms-field-label\" for=\"wpforms-59-field_37\">Other\/Description:<\/label><input type=\"text\" id=\"wpforms-59-field_37\" class=\"wpforms-field-medium\" name=\"wpforms[fields][37]\" ><\/div><div id=\"wpforms-59-field_52-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"52\"><label class=\"wpforms-field-label\" for=\"wpforms-59-field_52\">Integumentary<\/label><ul id=\"wpforms-59-field_52\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_52_1\" name=\"wpforms[fields][52][]\" value=\"Skin Rash\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_52_1\">Skin Rash<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_52_2\" name=\"wpforms[fields][52][]\" value=\"Easy Bruising\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_52_2\">Easy Bruising<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_52_3\" name=\"wpforms[fields][52][]\" value=\"Nail Problems\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_52_3\">Nail Problems<\/label><\/li><\/ul><\/div><div id=\"wpforms-59-field_38-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"38\"><label class=\"wpforms-field-label\" for=\"wpforms-59-field_38\">Other\/Description:<\/label><input type=\"text\" id=\"wpforms-59-field_38\" class=\"wpforms-field-medium\" name=\"wpforms[fields][38]\" ><\/div><div id=\"wpforms-59-field_53-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"53\"><label class=\"wpforms-field-label\" for=\"wpforms-59-field_53\">Musculoskeletal<\/label><ul id=\"wpforms-59-field_53\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_53_1\" name=\"wpforms[fields][53][]\" value=\"Joint Pain\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_53_1\">Joint Pain<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_53_2\" name=\"wpforms[fields][53][]\" value=\"Joint Swelling\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_53_2\">Joint Swelling<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_53_3\" name=\"wpforms[fields][53][]\" value=\"Back Pain\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_53_3\">Back Pain<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_53_4\" name=\"wpforms[fields][53][]\" value=\"Difficulty Ambulating (Walking)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_53_4\">Difficulty Ambulating (Walking)<\/label><\/li><\/ul><\/div><div id=\"wpforms-59-field_39-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"39\"><label class=\"wpforms-field-label\" for=\"wpforms-59-field_39\">Other\/Description:<\/label><input type=\"text\" id=\"wpforms-59-field_39\" class=\"wpforms-field-medium\" name=\"wpforms[fields][39]\" ><\/div><div id=\"wpforms-59-field_54-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"54\"><label class=\"wpforms-field-label\" for=\"wpforms-59-field_54\">Head\/Ear\/Nose\/Throat\/Mouth<\/label><ul id=\"wpforms-59-field_54\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_54_1\" name=\"wpforms[fields][54][]\" value=\"Ear or Sinus Pain\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_54_1\">Ear or Sinus Pain<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_54_2\" name=\"wpforms[fields][54][]\" value=\"Nasal Obstruction\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_54_2\">Nasal Obstruction<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_54_3\" name=\"wpforms[fields][54][]\" value=\"Sore Throat\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_54_3\">Sore Throat<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_54_4\" name=\"wpforms[fields][54][]\" value=\"Hearing Loss\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_54_4\">Hearing Loss<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_54_5\" name=\"wpforms[fields][54][]\" value=\"Headache\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_54_5\">Headache<\/label><\/li><\/ul><\/div><div id=\"wpforms-59-field_40-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"40\"><label class=\"wpforms-field-label\" for=\"wpforms-59-field_40\">Other\/Description:<\/label><input type=\"text\" id=\"wpforms-59-field_40\" class=\"wpforms-field-medium\" name=\"wpforms[fields][40]\" ><\/div><div id=\"wpforms-59-field_55-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"55\"><label class=\"wpforms-field-label\" for=\"wpforms-59-field_55\">Cardiovascular<\/label><ul id=\"wpforms-59-field_55\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_55_1\" name=\"wpforms[fields][55][]\" value=\"Chest Pain\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_55_1\">Chest Pain<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_55_2\" name=\"wpforms[fields][55][]\" value=\"Palpitations\/Irregular beats\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_55_2\">Palpitations\/Irregular beats<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_55_3\" name=\"wpforms[fields][55][]\" value=\"Calf Pain or Heavy Legs\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_55_3\">Calf Pain or Heavy Legs<\/label><\/li><\/ul><\/div><div id=\"wpforms-59-field_41-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"41\"><label class=\"wpforms-field-label\" for=\"wpforms-59-field_41\">Other\/Description:<\/label><input type=\"text\" id=\"wpforms-59-field_41\" class=\"wpforms-field-medium\" name=\"wpforms[fields][41]\" ><\/div><div id=\"wpforms-59-field_56-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"56\"><label class=\"wpforms-field-label\" for=\"wpforms-59-field_56\">Respiratory\/Lungs<\/label><ul id=\"wpforms-59-field_56\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_56_1\" name=\"wpforms[fields][56][]\" value=\"Wheezing\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_56_1\">Wheezing<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_56_2\" name=\"wpforms[fields][56][]\" value=\"Frequent Coughs\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_56_2\">Frequent Coughs<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_56_3\" name=\"wpforms[fields][56][]\" value=\"Sputum\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_56_3\">Sputum<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_56_4\" name=\"wpforms[fields][56][]\" value=\"Asthma\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_56_4\">Asthma<\/label><\/li><\/ul><\/div><div id=\"wpforms-59-field_42-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-59-field_42\">Other\/Description:<\/label><input type=\"text\" id=\"wpforms-59-field_42\" class=\"wpforms-field-medium\" name=\"wpforms[fields][42]\" ><\/div><div id=\"wpforms-59-field_57-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"57\"><label class=\"wpforms-field-label\" for=\"wpforms-59-field_57\">Breasts<\/label><ul id=\"wpforms-59-field_57\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_57_1\" name=\"wpforms[fields][57][]\" value=\"Implants\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_57_1\">Implants<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_57_2\" name=\"wpforms[fields][57][]\" value=\"Discharge\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_57_2\">Discharge<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-59-field_57_3\" name=\"wpforms[fields][57][]\" value=\"Fibrocystic Disease\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-59-field_57_3\">Fibrocystic Disease<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" 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