{"id":6477,"date":"2026-10-29T09:54:58","date_gmt":"2026-10-29T13:54:58","guid":{"rendered":"https:\/\/www.motivationminceur.ca\/new-patient-questionnaire\/"},"modified":"2026-10-29T10:28:56","modified_gmt":"2026-10-29T14:28:56","slug":"new-patient-questionnaire","status":"publish","type":"page","link":"https:\/\/www.motivationminceur.ca\/en\/new-patient-questionnaire\/","title":{"rendered":"New patient questionnaire"},"content":{"rendered":"<style>.mm-intake{max-width:760px;margin:0 auto;padding:24px 0 8px}.mm-intake h1{font-size:clamp(28px,5vw,40px);line-height:1.15;color:#0A1A30;margin:0 0 10px}.mm-intake .mm-lead{font-size:18px;color:#333;margin:0 0 20px}.mm-intake .mm-steps{display:grid;grid-template-columns:repeat(3,1fr);gap:12px;margin:0 0 20px}.mm-intake .mm-steps div{background:#f6fbef;border-radius:10px;padding:14px;font-size:15px;color:#0A1A30}.mm-intake .mm-steps b{display:block;font-size:22px;color:#7EB23D}.mm-intake .mm-private{font-size:14px;color:#555;border-left:4px solid #7EB23D;padding:8px 12px;margin:0 0 24px;background:#fafafa}.mm-intake-form{max-width:760px;margin:0 auto 48px}@media(max-width:600px){.mm-intake{padding-top:8px}.mm-intake .mm-lead{font-size:16px}.mm-intake .mm-steps{gap:8px}.mm-intake .mm-steps div{padding:10px 8px;font-size:12.5px;line-height:1.3}.mm-intake .mm-steps b{font-size:17px}}<\/style>\n<div class=\"mm-intake\">\n<h1>New patient questionnaire<\/h1>\n<p class=\"mm-lead\">Welcome to your program! Before your first appointment, help Dr. Larocque get to know you: your weight, your health, your habits and your goals.<\/p>\n<div class=\"mm-steps\">\n<div><b>10 min<\/b>to fill in the questionnaire<\/div>\n<div><b>7 steps<\/b>short and easy on a phone<\/div>\n<div><b>Save<\/b>and finish later if you need to<\/div>\n<\/div>\n<p class=\"mm-private\">&#x1f512; Your answers are confidential. They are only used to prepare and provide your follow-up with Dr. Larocque.<\/p>\n<\/div>\n<div class=\"mm-intake-form\"><script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 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var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-btn-bg-color-hover-tertiary: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_11' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_11' id='gform_11'  action='\/en\/wp-json\/wp\/v2\/pages\/6477#gf_11' data-formid='11' novalidate>\n        <div id='gf_progressbar_wrapper_11' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>7<\/span><span class='gf_step_page_name'> - You and your weight<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_green' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_green percentbar_14' style='width:14%;'><span>14%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_11_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_11' class='gform_fields top_label form_sublabel_above description_above validation_above' data-column-layout='fixed'><div id=\"field_11_1\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"><label id='gfield_label_11_1' class='gfield_label gform-field-label' for='input_11_1'><span class='gform-field-label__text'>First name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_11_1' type='text' value='' class=''     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_2\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"><label id='gfield_label_11_2' class='gfield_label gform-field-label' for='input_11_2'><span class='gform-field-label__text'>Last name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_11_2' type='text' value='' class=''     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_3\" class=\"gfield gfield--type-email gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"><label id='gfield_label_11_3' class='gfield_label gform-field-label' for='input_11_3'><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_11_3' type='email' value='' class=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_11_4\" class=\"gfield gfield--type-phone gfield--phone-format-international gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"><label id='gfield_label_11_4' class='gfield_label gform-field-label' for='input_11_4'><span class='gform-field-label__text'>Phone<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_11_4' type='tel' value='' class=''   aria-required=\"true\" aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_11_100\" class=\"gfield gfield--type-number gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"><label id='gfield_label_11_100' class='gfield_label gform-field-label' for='input_11_100'><span class='gform-field-label__text'>Age<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_100' id='input_11_100' type='number' step='any' min='12' max='110' value='' class=''     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_11_100\" \/><div class='gfield_description instruction ' id='gfield_instruction_11_100'>Please enter a number from <strong>12<\/strong> to <strong>110<\/strong>.<\/div><\/div><\/div><div id=\"field_11_13\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"><label id='gfield_label_11_13' class='gfield_label gform-field-label' for='input_11_13'><span class='gform-field-label__text'>Height<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_11_13' type='text' value='' class=''    placeholder='e.g. 5 ft 6 in or 168 cm' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_14\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"><label id='gfield_label_11_14' class='gfield_label gform-field-label' for='input_11_14'><span class='gform-field-label__text'>Current weight<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_11_14' type='text' value='' class=''    placeholder='e.g. 190 lb or 86 kg' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_15\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"><label id='gfield_label_11_15' class='gfield_label gform-field-label' for='input_11_15'><span class='gform-field-label__text'>Goal weight<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_11_15' type='text' value='' class=''     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_5\" class=\"gfield gfield--type-date gfield--input-type-datedropdown gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"><legend id='gfield_label_11_5' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Date of birth<\/span><\/legend><div id='input_11_5' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_11_5_1_container'><label for='input_11_5_1' id='input_11_5_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>MM<\/label><select name='input_5[]' id='input_11_5_1'   aria-required='false'   aria-labelledby=\"input_11_5_1_label gfield_label_11_5\" ><option value=''>MM<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_11_5_2_container'><label for='input_11_5_2' id='input_11_5_2_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>DD<\/label><select name='input_5[]' id='input_11_5_2'   aria-required='false'  ><option value=''>DD<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_11_5_3_container'><label for='input_11_5_3' id='input_11_5_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>YYYY<\/label><select name='input_5[]' id='input_11_5_3'   aria-required='false'  ><option value=''>YYYY<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><fieldset id=\"field_11_6\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"><legend id='gfield_label_11_6' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Sex<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_6'>\n\t\t\t<div class='gchoice gchoice_11_6_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Female'  id='choice_11_6_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_11_6_0 gfield_label_11_6\"   \/>\n\t\t\t\t\t<label for='choice_11_6_0' id='label_11_6_0' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_6_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Male'  id='choice_11_6_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_6_1' id='label_11_6_1' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_6_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Other or prefer not to say'  id='choice_11_6_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_6_2' id='label_11_6_2' class='gform-field-label gform-field-label--type-inline'>Other or prefer not to say<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_7\" class=\"gfield gfield--type-text field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"><label id='gfield_label_11_7' class='gfield_label gform-field-label' for='input_11_7'><span class='gform-field-label__text'>City and province<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_11_7' type='text' value='' class=''      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_8\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"><legend id='gfield_label_11_8' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Program purchased<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_8'>\n\t\t\t<div class='gchoice gchoice_11_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Motivation Weight Loss Program (coaching)'  id='choice_11_8_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_11_8_0 gfield_label_11_8\"   \/>\n\t\t\t\t\t<label for='choice_11_8_0' id='label_11_8_0' class='gform-field-label gform-field-label--type-inline'>Motivation Weight Loss Program (coaching)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Private consultation with Dr. Larocque'  id='choice_11_8_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_8_1' id='label_11_8_1' class='gform-field-label gform-field-label--type-inline'>Private consultation with Dr. Larocque<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_8_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Other'  id='choice_11_8_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_8_2' id='label_11_8_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_9\" class=\"gfield gfield--type-text field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"><label id='gfield_label_11_9' class='gfield_label gform-field-label' for='input_11_9'><span class='gform-field-label__text'>Order number (if you have it)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_11_9' type='text' value='' class=''      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_10\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"><legend id='gfield_label_11_10' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Preferred times for the first appointment<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_10'><div class='gchoice gchoice_11_10_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.1' type='checkbox'  value='Weekday mornings'  id='choice_11_10_1'    aria-labelledby=\"label_11_10_1 gfield_label_11_10\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_11_10_1' id='label_11_10_1' class='gform-field-label gform-field-label--type-inline'>Weekday mornings<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_10_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.2' type='checkbox'  value='Weekday afternoons'  id='choice_11_10_2'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_10_2' id='label_11_10_2' class='gform-field-label gform-field-label--type-inline'>Weekday afternoons<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_10_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.3' type='checkbox'  value='Weekday evenings'  id='choice_11_10_3'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_10_3' id='label_11_10_3' class='gform-field-label gform-field-label--type-inline'>Weekday evenings<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_10_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.4' type='checkbox'  value='Weekends'  id='choice_11_10_4'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_10_4' id='label_11_10_4' class='gform-field-label gform-field-label--type-inline'>Weekends<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_11\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"><legend id='gfield_label_11_11' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Appointment by<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_11'>\n\t\t\t<div class='gchoice gchoice_11_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Video call'  id='choice_11_11_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_11_11_0 gfield_label_11_11\"   \/>\n\t\t\t\t\t<label for='choice_11_11_0' id='label_11_11_0' class='gform-field-label gform-field-label--type-inline'>Video call<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Phone'  id='choice_11_11_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_11_1' id='label_11_11_1' class='gform-field-label gform-field-label--type-inline'>Phone<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_11_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='No preference'  id='choice_11_11_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_11_2' id='label_11_11_2' class='gform-field-label gform-field-label--type-inline'>No preference<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <button type='button' id='gform_next_button_11_12' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_11_2_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and finish later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_11_2' class='gform_page' data-js='page-field-id-12' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_11_2' class='gform_fields top_label form_sublabel_above description_above validation_above' data-column-layout='fixed'><div id=\"field_11_16\" class=\"gfield gfield--type-select gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"><label id='gfield_label_11_16' class='gfield_label gform-field-label' for='input_11_16'><span class='gform-field-label__text'>How soon would you like to reach it?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_16' id='input_11_16' class='gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='3 months' >3 months<\/option><option value='6 months' >6 months<\/option><option value='1 year' >1 year<\/option><option value='More than a year' >More than a year<\/option><option value='Not sure' >Not sure<\/option><\/select><\/div><\/div><div id=\"field_11_17\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"><label id='gfield_label_11_17' class='gfield_label gform-field-label' for='input_11_17'><span class='gform-field-label__text'>Why do you want to lose weight now? (your WHY)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_17' id='input_11_17' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_11_18\" class=\"gfield gfield--type-select field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"><label id='gfield_label_11_18' class='gfield_label gform-field-label' for='input_11_18'><span class='gform-field-label__text'>Your motivation today, from 1 (low) to 10 (very strong)<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_18' id='input_11_18' class='gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><\/select><\/div><\/div><fieldset id=\"field_11_19\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"><legend id='gfield_label_11_19' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Other goals<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_19'><div class='gchoice gchoice_11_19_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.1' type='checkbox'  value='More energy'  id='choice_11_19_1'    aria-labelledby=\"label_11_19_1 gfield_label_11_19\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_11_19_1' id='label_11_19_1' class='gform-field-label gform-field-label--type-inline'>More energy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_19_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.2' type='checkbox'  value='Better sleep'  id='choice_11_19_2'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_19_2' id='label_11_19_2' class='gform-field-label gform-field-label--type-inline'>Better sleep<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_19_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.3' type='checkbox'  value='Improve my health (blood sugar, blood pressure, cholesterol\u2026)'  id='choice_11_19_3'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_19_3' id='label_11_19_3' class='gform-field-label gform-field-label--type-inline'>Improve my health (blood sugar, blood pressure, cholesterol\u2026)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_19_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.4' type='checkbox'  value='Feel better about myself'  id='choice_11_19_4'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_19_4' id='label_11_19_4' class='gform-field-label gform-field-label--type-inline'>Feel better about myself<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_19_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.5' type='checkbox'  value='Better handle my emotions around food'  id='choice_11_19_5'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_19_5' id='label_11_19_5' class='gform-field-label gform-field-label--type-inline'>Better handle my emotions around food<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_19_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.6' type='checkbox'  value='Keep the weight off long term'  id='choice_11_19_6'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_19_6' id='label_11_19_6' class='gform-field-label gform-field-label--type-inline'>Keep the weight off long term<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_11_20' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_11_20' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_11_3_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and finish later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_11_3' class='gform_page' data-js='page-field-id-20' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_11_3' class='gform_fields top_label form_sublabel_above description_above validation_above' data-column-layout='fixed'><div id=\"field_11_21\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"><label id='gfield_label_11_21' class='gfield_label gform-field-label' for='input_11_21'><span class='gform-field-label__text'>Lowest adult weight<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_11_21' type='text' value='' class=''      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_22\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"><label id='gfield_label_11_22' class='gfield_label gform-field-label' for='input_11_22'><span class='gform-field-label__text'>Highest weight<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_11_22' type='text' value='' class=''      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_23\" class=\"gfield gfield--type-select field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"><label id='gfield_label_11_23' class='gfield_label gform-field-label' for='input_11_23'><span class='gform-field-label__text'>Since when have you been overweight?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_23' id='input_11_23' class='gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Since childhood' >Since childhood<\/option><option value='Since my teens' >Since my teens<\/option><option value='Since a pregnancy' >Since a pregnancy<\/option><option value='For 1 to 5 years' >For 1 to 5 years<\/option><option value='For more than 5 years' >For more than 5 years<\/option><\/select><\/div><\/div><fieldset id=\"field_11_24\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"><legend id='gfield_label_11_24' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Methods you have tried<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_24'><div class='gchoice gchoice_11_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='Counting calories \/ low-calorie diet'  id='choice_11_24_1'    aria-labelledby=\"label_11_24_1 gfield_label_11_24\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_11_24_1' id='label_11_24_1' class='gform-field-label gform-field-label--type-inline'>Counting calories \/ low-calorie diet<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='Weight Watchers (WW)'  id='choice_11_24_2'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_24_2' id='label_11_24_2' class='gform-field-label gform-field-label--type-inline'>Weight Watchers (WW)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_24_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.3' type='checkbox'  value='High-protein diet \/ meal replacements'  id='choice_11_24_3'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_24_3' id='label_11_24_3' class='gform-field-label gform-field-label--type-inline'>High-protein diet \/ meal replacements<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_24_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.4' type='checkbox'  value='Keto \/ low-carb'  id='choice_11_24_4'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_24_4' id='label_11_24_4' class='gform-field-label gform-field-label--type-inline'>Keto \/ low-carb<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_24_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.5' type='checkbox'  value='Intermittent fasting'  id='choice_11_24_5'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_24_5' id='label_11_24_5' class='gform-field-label gform-field-label--type-inline'>Intermittent fasting<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_24_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.6' type='checkbox'  value='Medication (Ozempic, Wegovy, Mounjaro, Saxenda\u2026)'  id='choice_11_24_6'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_24_6' id='label_11_24_6' class='gform-field-label gform-field-label--type-inline'>Medication (Ozempic, Wegovy, Mounjaro, Saxenda\u2026)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_24_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.7' type='checkbox'  value='Bariatric surgery'  id='choice_11_24_7'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_24_7' id='label_11_24_7' class='gform-field-label gform-field-label--type-inline'>Bariatric surgery<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_24_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.8' type='checkbox'  value='Follow-up with a professional'  id='choice_11_24_8'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_24_8' id='label_11_24_8' class='gform-field-label gform-field-label--type-inline'>Follow-up with a professional<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_24_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.9' type='checkbox'  value='None'  id='choice_11_24_9'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_24_9' id='label_11_24_9' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_25\" class=\"gfield gfield--type-textarea field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"><label id='gfield_label_11_25' class='gfield_label gform-field-label' for='input_11_25'><span class='gform-field-label__text'>What worked, and why did the weight come back?<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_25' id='input_11_25' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_11_26' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_11_26' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_11_4_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and finish later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_11_4' class='gform_page' data-js='page-field-id-26' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_11_4' class='gform_fields top_label form_sublabel_above description_above validation_above' data-column-layout='fixed'><fieldset id=\"field_11_27\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"><legend id='gfield_label_11_27' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Do you have any of these health conditions?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_27'><div class='gchoice gchoice_11_27_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.1' type='checkbox'  value='Type 2 diabetes'  id='choice_11_27_1'    aria-labelledby=\"label_11_27_1 gfield_label_11_27\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_11_27_1' id='label_11_27_1' class='gform-field-label gform-field-label--type-inline'>Type 2 diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_27_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.2' type='checkbox'  value='Prediabetes \/ insulin resistance'  id='choice_11_27_2'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_27_2' id='label_11_27_2' class='gform-field-label gform-field-label--type-inline'>Prediabetes \/ insulin resistance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_27_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.3' type='checkbox'  value='High blood pressure'  id='choice_11_27_3'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_27_3' id='label_11_27_3' class='gform-field-label gform-field-label--type-inline'>High blood pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_27_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.4' type='checkbox'  value='High cholesterol'  id='choice_11_27_4'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_27_4' id='label_11_27_4' class='gform-field-label gform-field-label--type-inline'>High cholesterol<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_27_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.5' type='checkbox'  value='Heart disease'  id='choice_11_27_5'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_27_5' id='label_11_27_5' class='gform-field-label gform-field-label--type-inline'>Heart disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_27_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.6' type='checkbox'  value='Sleep apnea'  id='choice_11_27_6'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_27_6' id='label_11_27_6' class='gform-field-label gform-field-label--type-inline'>Sleep apnea<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_27_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.7' type='checkbox'  value='Hypothyroidism'  id='choice_11_27_7'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_27_7' id='label_11_27_7' class='gform-field-label gform-field-label--type-inline'>Hypothyroidism<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_27_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.8' type='checkbox'  value='Polycystic ovary syndrome (PCOS)'  id='choice_11_27_8'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_27_8' id='label_11_27_8' class='gform-field-label gform-field-label--type-inline'>Polycystic ovary syndrome (PCOS)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_27_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.9' type='checkbox'  value='Kidney disease'  id='choice_11_27_9'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_27_9' id='label_11_27_9' class='gform-field-label gform-field-label--type-inline'>Kidney disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_27_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.11' type='checkbox'  value='Liver disease (fatty liver\u2026)'  id='choice_11_27_11'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_27_11' id='label_11_27_11' class='gform-field-label gform-field-label--type-inline'>Liver disease (fatty liver\u2026)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_27_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.12' type='checkbox'  value='Digestive problems'  id='choice_11_27_12'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_27_12' id='label_11_27_12' class='gform-field-label gform-field-label--type-inline'>Digestive problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_27_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.13' type='checkbox'  value='Joint pain'  id='choice_11_27_13'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_27_13' id='label_11_27_13' class='gform-field-label gform-field-label--type-inline'>Joint pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_27_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.14' type='checkbox'  value='Depression or anxiety'  id='choice_11_27_14'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_27_14' id='label_11_27_14' class='gform-field-label gform-field-label--type-inline'>Depression or anxiety<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_27_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.15' type='checkbox'  value='Eating disorder (current or past)'  id='choice_11_27_15'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_27_15' id='label_11_27_15' class='gform-field-label gform-field-label--type-inline'>Eating disorder (current or past)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_27_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.16' type='checkbox'  value='None'  id='choice_11_27_16'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_27_16' id='label_11_27_16' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_28\" class=\"gfield gfield--type-textarea field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"><label id='gfield_label_11_28' class='gfield_label gform-field-label' for='input_11_28'><span class='gform-field-label__text'>Other health problems or surgeries<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_28' id='input_11_28' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_11_29\" class=\"gfield gfield--type-textarea field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"><label id='gfield_label_11_29' class='gfield_label gform-field-label' for='input_11_29'><span class='gform-field-label__text'>Medications and supplements you take (with dose)<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_29' id='input_11_29' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_11_30\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"><legend id='gfield_label_11_30' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you take a weight-loss medication (Ozempic, Wegovy, Mounjaro\u2026)?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_30'>\n\t\t\t<div class='gchoice gchoice_11_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='No'  id='choice_11_30_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_11_30_0 gfield_label_11_30\"   \/>\n\t\t\t\t\t<label for='choice_11_30_0' id='label_11_30_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Yes, currently'  id='choice_11_30_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_30_1' id='label_11_30_1' class='gform-field-label gform-field-label--type-inline'>Yes, currently<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_30_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Yes, in the past'  id='choice_11_30_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_30_2' id='label_11_30_2' class='gform-field-label gform-field-label--type-inline'>Yes, in the past<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_31\" class=\"gfield gfield--type-textarea field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"><label id='gfield_label_11_31' class='gfield_label gform-field-label' for='input_11_31'><span class='gform-field-label__text'>Food allergies or intolerances<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_31' id='input_11_31' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_11_32\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"><legend id='gfield_label_11_32' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you pregnant, planning a pregnancy or breastfeeding?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_32'>\n\t\t\t<div class='gchoice gchoice_11_32_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='No'  id='choice_11_32_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_11_32_0 gfield_label_11_32\"   \/>\n\t\t\t\t\t<label for='choice_11_32_0' id='label_11_32_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_32_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Yes'  id='choice_11_32_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_32_1' id='label_11_32_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_32_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Not applicable'  id='choice_11_32_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_32_2' id='label_11_32_2' class='gform-field-label gform-field-label--type-inline'>Not applicable<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_33\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"><legend id='gfield_label_11_33' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you have a family doctor?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_33'>\n\t\t\t<div class='gchoice gchoice_11_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Yes'  id='choice_11_33_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_11_33_0 gfield_label_11_33\"   \/>\n\t\t\t\t\t<label for='choice_11_33_0' id='label_11_33_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='No'  id='choice_11_33_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_33_1' id='label_11_33_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_34\" class=\"gfield gfield--type-textarea field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"><label id='gfield_label_11_34' class='gfield_label gform-field-label' for='input_11_34'><span class='gform-field-label__text'>Recent results if you have them (blood tests, blood pressure\u2026)<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_34' id='input_11_34' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_11_35' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_11_35' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_11_5_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and finish later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_11_5' class='gform_page' data-js='page-field-id-35' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_11_5' class='gform_fields top_label form_sublabel_above description_above validation_above' data-column-layout='fixed'><div id=\"field_11_36\" class=\"gfield gfield--type-select gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"><label id='gfield_label_11_36' class='gfield_label gform-field-label' for='input_11_36'><span class='gform-field-label__text'>Meals per day<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_36' id='input_11_36' class='gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4 or more' >4 or more<\/option><\/select><\/div><\/div><fieldset id=\"field_11_37\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"><legend id='gfield_label_11_37' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you eat breakfast?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_37'>\n\t\t\t<div class='gchoice gchoice_11_37_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Every day'  id='choice_11_37_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_11_37_0 gfield_label_11_37\"   \/>\n\t\t\t\t\t<label for='choice_11_37_0' id='label_11_37_0' class='gform-field-label gform-field-label--type-inline'>Every day<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_37_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Sometimes'  id='choice_11_37_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_37_1' id='label_11_37_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_37_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Rarely'  id='choice_11_37_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_37_2' id='label_11_37_2' class='gform-field-label gform-field-label--type-inline'>Rarely<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_38\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"><legend id='gfield_label_11_38' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Snacks<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_38'>\n\t\t\t<div class='gchoice gchoice_11_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Never'  id='choice_11_38_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_11_38_0 gfield_label_11_38\"   \/>\n\t\t\t\t\t<label for='choice_11_38_0' id='label_11_38_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='1 to 2 a day'  id='choice_11_38_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_38_1' id='label_11_38_1' class='gform-field-label gform-field-label--type-inline'>1 to 2 a day<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_38_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='3 or more a day'  id='choice_11_38_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_38_2' id='label_11_38_2' class='gform-field-label gform-field-label--type-inline'>3 or more a day<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_39\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"><legend id='gfield_label_11_39' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Hardest times<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_39'><div class='gchoice gchoice_11_39_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.1' type='checkbox'  value='Morning'  id='choice_11_39_1'    aria-labelledby=\"label_11_39_1 gfield_label_11_39\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_11_39_1' id='label_11_39_1' class='gform-field-label gform-field-label--type-inline'>Morning<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_39_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.2' type='checkbox'  value='Afternoon'  id='choice_11_39_2'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_39_2' id='label_11_39_2' class='gform-field-label gform-field-label--type-inline'>Afternoon<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_39_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.3' type='checkbox'  value='Evening'  id='choice_11_39_3'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_39_3' id='label_11_39_3' class='gform-field-label gform-field-label--type-inline'>Evening<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_39_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.4' type='checkbox'  value='Night'  id='choice_11_39_4'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_39_4' id='label_11_39_4' class='gform-field-label gform-field-label--type-inline'>Night<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_39_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.5' type='checkbox'  value='Weekends'  id='choice_11_39_5'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_39_5' id='label_11_39_5' class='gform-field-label gform-field-label--type-inline'>Weekends<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_39_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.6' type='checkbox'  value='Restaurants and outings'  id='choice_11_39_6'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_39_6' id='label_11_39_6' class='gform-field-label gform-field-label--type-inline'>Restaurants and outings<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_39_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.7' type='checkbox'  value='At work'  id='choice_11_39_7'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_39_7' id='label_11_39_7' class='gform-field-label gform-field-label--type-inline'>At work<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_40\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"><legend id='gfield_label_11_40' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Your cravings<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_40'><div class='gchoice gchoice_11_40_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.1' type='checkbox'  value='Sweet'  id='choice_11_40_1'    aria-labelledby=\"label_11_40_1 gfield_label_11_40\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_11_40_1' id='label_11_40_1' class='gform-field-label gform-field-label--type-inline'>Sweet<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_40_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.2' type='checkbox'  value='Salty'  id='choice_11_40_2'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_40_2' id='label_11_40_2' class='gform-field-label gform-field-label--type-inline'>Salty<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_40_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.3' type='checkbox'  value='Fatty \/ fried'  id='choice_11_40_3'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_40_3' id='label_11_40_3' class='gform-field-label gform-field-label--type-inline'>Fatty \/ fried<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_40_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.4' type='checkbox'  value='Bread and starches'  id='choice_11_40_4'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_40_4' id='label_11_40_4' class='gform-field-label gform-field-label--type-inline'>Bread and starches<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_40_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.5' type='checkbox'  value='No particular cravings'  id='choice_11_40_5'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_40_5' id='label_11_40_5' class='gform-field-label gform-field-label--type-inline'>No particular cravings<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_41\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"><legend id='gfield_label_11_41' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Alcohol<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_41'>\n\t\t\t<div class='gchoice gchoice_11_41_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Never'  id='choice_11_41_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_11_41_0 gfield_label_11_41\"   \/>\n\t\t\t\t\t<label for='choice_11_41_0' id='label_11_41_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_41_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Occasionally'  id='choice_11_41_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_41_1' id='label_11_41_1' class='gform-field-label gform-field-label--type-inline'>Occasionally<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_41_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='1 to 3 times a week'  id='choice_11_41_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_41_2' id='label_11_41_2' class='gform-field-label gform-field-label--type-inline'>1 to 3 times a week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_41_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='4 or more times a week'  id='choice_11_41_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_41_3' id='label_11_41_3' class='gform-field-label gform-field-label--type-inline'>4 or more times a week<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_42\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"><legend id='gfield_label_11_42' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Sugary drinks (soft drinks, juice\u2026)<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_42'>\n\t\t\t<div class='gchoice gchoice_11_42_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Never'  id='choice_11_42_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_11_42_0 gfield_label_11_42\"   \/>\n\t\t\t\t\t<label for='choice_11_42_0' id='label_11_42_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_42_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Occasionally'  id='choice_11_42_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_42_1' id='label_11_42_1' class='gform-field-label gform-field-label--type-inline'>Occasionally<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_42_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='1 to 3 times a week'  id='choice_11_42_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_42_2' id='label_11_42_2' class='gform-field-label gform-field-label--type-inline'>1 to 3 times a week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_42_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='4 or more times a week'  id='choice_11_42_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_42_3' id='label_11_42_3' class='gform-field-label gform-field-label--type-inline'>4 or more times a week<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_43\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"><legend id='gfield_label_11_43' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Who cooks at home?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_43'>\n\t\t\t<div class='gchoice gchoice_11_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Me'  id='choice_11_43_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_11_43_0 gfield_label_11_43\"   \/>\n\t\t\t\t\t<label for='choice_11_43_0' id='label_11_43_0' class='gform-field-label gform-field-label--type-inline'>Me<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='My partner'  id='choice_11_43_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_43_1' id='label_11_43_1' class='gform-field-label gform-field-label--type-inline'>My partner<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_43_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Shared'  id='choice_11_43_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_43_2' id='label_11_43_2' class='gform-field-label gform-field-label--type-inline'>Shared<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_43_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='I mostly eat out'  id='choice_11_43_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_43_3' id='label_11_43_3' class='gform-field-label gform-field-label--type-inline'>I mostly eat out<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_44\" class=\"gfield gfield--type-textarea field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"><label id='gfield_label_11_44' class='gfield_label gform-field-label' for='input_11_44'><span class='gform-field-label__text'>Describe what you eat on a typical day<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_44' id='input_11_44' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_11_45' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_11_45' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_11_6_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and finish later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_11_6' class='gform_page' data-js='page-field-id-45' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_11_6' class='gform_fields top_label form_sublabel_above description_above validation_above' data-column-layout='fixed'><fieldset id=\"field_11_46\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"><legend id='gfield_label_11_46' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you eat because of your emotions?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_46'>\n\t\t\t<div class='gchoice gchoice_11_46_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Never'  id='choice_11_46_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_11_46_0 gfield_label_11_46\"   \/>\n\t\t\t\t\t<label for='choice_11_46_0' id='label_11_46_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_46_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Sometimes'  id='choice_11_46_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_46_1' id='label_11_46_1' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_46_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Often'  id='choice_11_46_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_46_2' id='label_11_46_2' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_46_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Almost always'  id='choice_11_46_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_46_3' id='label_11_46_3' class='gform-field-label gform-field-label--type-inline'>Almost always<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_47\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"><legend id='gfield_label_11_47' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>What makes you eat<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_47'><div class='gchoice gchoice_11_47_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.1' type='checkbox'  value='Stress'  id='choice_11_47_1'    aria-labelledby=\"label_11_47_1 gfield_label_11_47\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_11_47_1' id='label_11_47_1' class='gform-field-label gform-field-label--type-inline'>Stress<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_47_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.2' type='checkbox'  value='Boredom'  id='choice_11_47_2'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_47_2' id='label_11_47_2' class='gform-field-label gform-field-label--type-inline'>Boredom<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_47_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.3' type='checkbox'  value='Fatigue'  id='choice_11_47_3'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_47_3' id='label_11_47_3' class='gform-field-label gform-field-label--type-inline'>Fatigue<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_47_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.4' type='checkbox'  value='Loneliness'  id='choice_11_47_4'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_47_4' id='label_11_47_4' class='gform-field-label gform-field-label--type-inline'>Loneliness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_47_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.5' type='checkbox'  value='Sadness'  id='choice_11_47_5'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_47_5' id='label_11_47_5' class='gform-field-label gform-field-label--type-inline'>Sadness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_47_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.6' type='checkbox'  value='Anger or frustration'  id='choice_11_47_6'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_47_6' id='label_11_47_6' class='gform-field-label gform-field-label--type-inline'>Anger or frustration<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_47_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.7' type='checkbox'  value='Reward or celebration'  id='choice_11_47_7'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_47_7' id='label_11_47_7' class='gform-field-label gform-field-label--type-inline'>Reward or celebration<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_47_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.8' type='checkbox'  value='Anxiety'  id='choice_11_47_8'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_47_8' id='label_11_47_8' class='gform-field-label gform-field-label--type-inline'>Anxiety<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_48\" class=\"gfield gfield--type-select gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"><label id='gfield_label_11_48' class='gfield_label gform-field-label' for='input_11_48'><span class='gform-field-label__text'>Hours of sleep per night<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_48' id='input_11_48' class='gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Less than 5' >Less than 5<\/option><option value='5 \u2013 6' >5 \u2013 6<\/option><option value='7 \u2013 8' >7 \u2013 8<\/option><option value='9 or more' >9 or more<\/option><\/select><\/div><\/div><fieldset id=\"field_11_49\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"><legend id='gfield_label_11_49' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Sleep quality<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_49'>\n\t\t\t<div class='gchoice gchoice_11_49_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Good'  id='choice_11_49_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_11_49_0 gfield_label_11_49\"   \/>\n\t\t\t\t\t<label for='choice_11_49_0' id='label_11_49_0' class='gform-field-label gform-field-label--type-inline'>Good<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_49_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Average'  id='choice_11_49_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_49_1' id='label_11_49_1' class='gform-field-label gform-field-label--type-inline'>Average<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_49_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Poor'  id='choice_11_49_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_49_2' id='label_11_49_2' class='gform-field-label gform-field-label--type-inline'>Poor<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_50\" class=\"gfield gfield--type-select gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"><label id='gfield_label_11_50' class='gfield_label gform-field-label' for='input_11_50'><span class='gform-field-label__text'>Your stress level, from 1 (low) to 10 (very high)<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_50' id='input_11_50' class='gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><\/select><\/div><\/div><fieldset id=\"field_11_51\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"><legend id='gfield_label_11_51' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Physical activity<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_51'>\n\t\t\t<div class='gchoice gchoice_11_51_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='None'  id='choice_11_51_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_11_51_0 gfield_label_11_51\"   \/>\n\t\t\t\t\t<label for='choice_11_51_0' id='label_11_51_0' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_51_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='1 to 2 times a week'  id='choice_11_51_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_51_1' id='label_11_51_1' class='gform-field-label gform-field-label--type-inline'>1 to 2 times a week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_51_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='3 to 4 times a week'  id='choice_11_51_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_51_2' id='label_11_51_2' class='gform-field-label gform-field-label--type-inline'>3 to 4 times a week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_51_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='5 or more times'  id='choice_11_51_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_51_3' id='label_11_51_3' class='gform-field-label gform-field-label--type-inline'>5 or more times<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_52\" class=\"gfield gfield--type-text field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"><label id='gfield_label_11_52' class='gfield_label gform-field-label' for='input_11_52'><span class='gform-field-label__text'>What kind of activity?<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_11_52' type='text' value='' class=''      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_53\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"><legend id='gfield_label_11_53' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Work schedule<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_53'>\n\t\t\t<div class='gchoice gchoice_11_53_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Days'  id='choice_11_53_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_11_53_0 gfield_label_11_53\"   \/>\n\t\t\t\t\t<label for='choice_11_53_0' id='label_11_53_0' class='gform-field-label gform-field-label--type-inline'>Days<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_53_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Evenings or nights'  id='choice_11_53_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_53_1' id='label_11_53_1' class='gform-field-label gform-field-label--type-inline'>Evenings or nights<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_53_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Rotating shifts'  id='choice_11_53_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_53_2' id='label_11_53_2' class='gform-field-label gform-field-label--type-inline'>Rotating shifts<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_53_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Not working \/ retired'  id='choice_11_53_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_53_3' id='label_11_53_3' class='gform-field-label gform-field-label--type-inline'>Not working \/ retired<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_11_54' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Previous<\/button> <button type='button' id='gform_next_button_11_54' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> <button type='button'  id='gform_save_11_7_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  ><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and finish later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_11_7' class='gform_page' data-js='page-field-id-54' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_11_7' class='gform_fields top_label form_sublabel_above description_above validation_above' data-column-layout='fixed'><fieldset id=\"field_11_55\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"><legend id='gfield_label_11_55' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do the people around you support you?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_55'>\n\t\t\t<div class='gchoice gchoice_11_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Yes, a lot'  id='choice_11_55_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_11_55_0 gfield_label_11_55\"   \/>\n\t\t\t\t\t<label for='choice_11_55_0' id='label_11_55_0' class='gform-field-label gform-field-label--type-inline'>Yes, a lot<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='A little'  id='choice_11_55_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_55_1' id='label_11_55_1' class='gform-field-label gform-field-label--type-inline'>A little<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_55_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Not really'  id='choice_11_55_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_11_55_2' id='label_11_55_2' class='gform-field-label gform-field-label--type-inline'>Not really<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_56\" class=\"gfield 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