{"id":3893,"date":"2023-06-12T09:46:39","date_gmt":"2023-06-12T09:46:39","guid":{"rendered":"https:\/\/wordpress-833442-3554657.cloudwaysapps.com\/?page_id=3893"},"modified":"2023-06-21T12:42:56","modified_gmt":"2023-06-21T12:42:56","slug":"client-symptioms-questionaire","status":"publish","type":"page","link":"https:\/\/hopemedicalgroups.com\/client-symptioms-questionaire\/","title":{"rendered":"Client Symptoms Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3893\" class=\"elementor elementor-3893\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-40fbc4a elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"40fbc4a\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-61d887e\" data-id=\"61d887e\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-302436f elementor-widget elementor-widget-heading\" data-id=\"302436f\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.15.0 - 20-08-2023 *\/\n.elementor-heading-title{padding:0;margin:0;line-height:1}.elementor-widget-heading .elementor-heading-title[class*=elementor-size-]>a{color:inherit;font-size:inherit;line-height:inherit}.elementor-widget-heading .elementor-heading-title.elementor-size-small{font-size:15px}.elementor-widget-heading .elementor-heading-title.elementor-size-medium{font-size:19px}.elementor-widget-heading .elementor-heading-title.elementor-size-large{font-size:29px}.elementor-widget-heading .elementor-heading-title.elementor-size-xl{font-size:39px}.elementor-widget-heading .elementor-heading-title.elementor-size-xxl{font-size:59px}<\/style><h2 class=\"elementor-heading-title elementor-size-default\">Client Symptom Questionnaire<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-448a66d elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"448a66d\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-25da51d\" data-id=\"25da51d\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-32f54b3 elementor-button-align-start elementor-widget elementor-widget-form\" data-id=\"32f54b3\" data-element_type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;button_width&quot;:&quot;100&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor-pro - v3.15.0 - 09-08-2023 *\/\n.elementor-button.elementor-hidden,.elementor-hidden{display:none}.e-form__step{width:100%}.e-form__step:not(.elementor-hidden){display:flex;flex-wrap:wrap}.e-form__buttons{flex-wrap:wrap}.e-form__buttons,.e-form__buttons__wrapper{display:flex}.e-form__indicators{display:flex;justify-content:space-between;align-items:center;flex-wrap:nowrap;font-size:13px;margin-bottom:var(--e-form-steps-indicators-spacing)}.e-form__indicators__indicator{display:flex;flex-direction:column;align-items:center;justify-content:center;flex-basis:0;padding:0 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.select-caret-down-wrapper{position:absolute;top:50%;transform:translateY(-50%);inset-inline-end:10px;pointer-events:none;font-size:11px}.elementor-select-wrapper .select-caret-down-wrapper svg{display:unset;width:1em;aspect-ratio:unset;fill:currentColor}.elementor-select-wrapper .select-caret-down-wrapper i{font-size:19px;line-height:2}.elementor-select-wrapper.remove-before:before{content:\"\"!important}<\/style>\t\t<form class=\"elementor-form\" method=\"post\" name=\"New Form\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"3893\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"32f54b3\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"\" \/>\n\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-name elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPatient\u2019s Name*\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[name]\" id=\"form-field-name\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"First name \" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_2c203ca elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2c203ca\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLast name* \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_2c203ca]\" id=\"form-field-field_2c203ca\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Last name \" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-field_0a2e8b3 elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0a2e8b3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmail Address*\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[field_0a2e8b3]\" id=\"form-field-field_0a2e8b3\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Your Email\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_283a4e1 elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_283a4e1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMobile Number*\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_283a4e1]\" id=\"form-field-field_283a4e1\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Mobile No.\" required=\"required\" aria-required=\"true\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_b7f37d2 elementor-col-100\">\n\t\t\t\t\tIs this related to an auto accident or work injury?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_e7073cf elementor-col-20\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Auto Accident\" id=\"form-field-field_e7073cf-0\" name=\"form_fields[field_e7073cf]\"> <label for=\"form-field-field_e7073cf-0\">Auto Accident<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_11904bb elementor-col-50\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Work Injury\" id=\"form-field-field_11904bb-0\" name=\"form_fields[field_11904bb]\"> <label for=\"form-field-field_11904bb-0\">Work Injury<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_46c69b6 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_46c69b6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIncident Date\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_46c69b6]\" id=\"form-field-field_46c69b6\" class=\"elementor-field elementor-size-md  elementor-field-textual elementor-date-field\" placeholder=\"dd\/mm\/yyyy\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_c780d92 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c780d92\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tToday\u2019s Date\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_c780d92]\" id=\"form-field-field_c780d92\" class=\"elementor-field elementor-size-md  elementor-field-textual elementor-date-field\" placeholder=\"dd\/mm\/yyyy\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_94c6d82 elementor-col-100\">\n\t\t\t\t\t\n\n\n<B>PLEASE CHECK ALL THAT APPLY :<\/B>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_4e6f88a elementor-col-100\">\n\t\t\t\t\t<B>Head<\/B>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_4168cae elementor-col-20 elementor-md-25\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"NECK PAIN\" id=\"form-field-field_4168cae-0\" name=\"form_fields[field_4168cae]\"> <label for=\"form-field-field_4168cae-0\">NECK PAIN<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_1df8742 elementor-col-20 elementor-md-25\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"HEADACHES\" id=\"form-field-field_1df8742-0\" name=\"form_fields[field_1df8742]\"> <label for=\"form-field-field_1df8742-0\">HEADACHES<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_8abac3a elementor-col-20 elementor-md-25\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"FACE PAIN\" id=\"form-field-field_8abac3a-0\" name=\"form_fields[field_8abac3a]\"> <label for=\"form-field-field_8abac3a-0\">FACE PAIN<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_8909c43 elementor-col-20 elementor-md-25\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"DIZZINESS\" id=\"form-field-field_8909c43-0\" name=\"form_fields[field_8909c43]\"> <label for=\"form-field-field_8909c43-0\">DIZZINESS<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_9dbd4f3 elementor-col-20 elementor-md-33\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"DIFFICULTY WALKING\" id=\"form-field-field_9dbd4f3-0\" name=\"form_fields[field_9dbd4f3]\"> <label for=\"form-field-field_9dbd4f3-0\">DIFFICULTY WALKING<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_5dff869 elementor-col-20 elementor-md-33\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"BALANCE PROBLEMS\" id=\"form-field-field_5dff869-0\" name=\"form_fields[field_5dff869]\"> <label for=\"form-field-field_5dff869-0\">BALANCE PROBLEMS<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_766de2b elementor-col-20 elementor-md-33\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"CONFUSED\" id=\"form-field-field_766de2b-0\" name=\"form_fields[field_766de2b]\"> <label for=\"form-field-field_766de2b-0\">CONFUSED<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_02aab2e elementor-col-20 elementor-md-33\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"DAYDREAMING\" id=\"form-field-field_02aab2e-0\" name=\"form_fields[field_02aab2e]\"> <label for=\"form-field-field_02aab2e-0\">DAYDREAMING<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_86d0dde elementor-col-20 elementor-md-33\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"ATTENTION ISSUES\" id=\"form-field-field_86d0dde-0\" name=\"form_fields[field_86d0dde]\"> <label for=\"form-field-field_86d0dde-0\">ATTENTION ISSUES<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_d41e54a elementor-col-20 elementor-md-33\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"HEARING ISSUES\" id=\"form-field-field_d41e54a-0\" name=\"form_fields[field_d41e54a]\"> <label for=\"form-field-field_d41e54a-0\">HEARING ISSUES<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_f696614 elementor-col-20 elementor-md-33\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"DIFFICULTY SPEAKING\" id=\"form-field-field_f696614-0\" name=\"form_fields[field_f696614]\"> <label for=\"form-field-field_f696614-0\">DIFFICULTY SPEAKING<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_3715742 elementor-col-20 elementor-md-33\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"MEMORY LOSS\" id=\"form-field-field_3715742-0\" name=\"form_fields[field_3715742]\"> <label for=\"form-field-field_3715742-0\">MEMORY LOSS<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_5825613 elementor-col-20 elementor-md-33\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"TIRED OR FATIGUED\" id=\"form-field-field_5825613-0\" name=\"form_fields[field_5825613]\"> <label for=\"form-field-field_5825613-0\">TIRED OR FATIGUED<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_e9c6af0 elementor-col-20 elementor-md-33\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"APPETITE CHANGE\" id=\"form-field-field_e9c6af0-0\" name=\"form_fields[field_e9c6af0]\"> <label for=\"form-field-field_e9c6af0-0\">APPETITE CHANGE<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_5e0d25c elementor-col-20 elementor-md-33\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"DIFFICULTY SLEEPING\" id=\"form-field-field_5e0d25c-0\" name=\"form_fields[field_5e0d25c]\"> <label for=\"form-field-field_5e0d25c-0\">DIFFICULTY SLEEPING<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_f385d9a elementor-col-20 elementor-md-33\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"BLURRED VISION\" id=\"form-field-field_f385d9a-0\" name=\"form_fields[field_f385d9a]\"> <label for=\"form-field-field_f385d9a-0\">BLURRED VISION<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_557fd7c elementor-col-20 elementor-md-33\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"NAUSEA\/VOMITING\" id=\"form-field-field_557fd7c-0\" name=\"form_fields[field_557fd7c]\"> <label for=\"form-field-field_557fd7c-0\">NAUSEA\/VOMITING<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_cd26135 elementor-col-20 elementor-md-33\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"MOOD SWINGS\" id=\"form-field-field_cd26135-0\" name=\"form_fields[field_cd26135]\"> <label for=\"form-field-field_cd26135-0\">MOOD SWINGS<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_345c335 elementor-col-20 elementor-md-33\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"SADNESS\" id=\"form-field-field_345c335-0\" name=\"form_fields[field_345c335]\"> <label for=\"form-field-field_345c335-0\">SADNESS<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_55fa40c elementor-col-20 elementor-md-33\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"AGITATION\" id=\"form-field-field_55fa40c-0\" name=\"form_fields[field_55fa40c]\"> <label for=\"form-field-field_55fa40c-0\">AGITATION<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_c014388 elementor-col-25 elementor-md-50\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"DISORIENTED\/ROOM SPINS\" id=\"form-field-field_c014388-0\" name=\"form_fields[field_c014388]\"> <label for=\"form-field-field_c014388-0\">DISORIENTED\/ROOM SPINS<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_0c820b3 elementor-col-30 elementor-md-50\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"CHANGE IN SENSE OF SMELL\/TASTE\" id=\"form-field-field_0c820b3-0\" name=\"form_fields[field_0c820b3]\"> <label for=\"form-field-field_0c820b3-0\">CHANGE IN SENSE OF SMELL\/TASTE<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_9d20a4a elementor-col-25 elementor-md-50\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"VISUAL DISTURBANCES\" id=\"form-field-field_9d20a4a-0\" name=\"form_fields[field_9d20a4a]\"> <label for=\"form-field-field_9d20a4a-0\">VISUAL DISTURBANCES<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_e91722f elementor-col-25 elementor-md-50\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"FLASHBACKS TO ACCIDENT\" id=\"form-field-field_e91722f-0\" name=\"form_fields[field_e91722f]\"> <label for=\"form-field-field_e91722f-0\">FLASHBACKS TO ACCIDENT<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_eb7e561 elementor-col-30 elementor-md-50\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"PROBLEMS READING OR WRITING\" id=\"form-field-field_eb7e561-0\" name=\"form_fields[field_eb7e561]\"> <label for=\"form-field-field_eb7e561-0\">PROBLEMS READING OR WRITING<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_fd7dbbc elementor-col-100\">\n\t\t\t\t\t<b>Neck<\/b>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_dcd237a elementor-col-100\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"NECK PAIN, NUMBNESS, TINGLING, AND\/OR WEAKNESS THAT RADIATES OR GOES DOWN TO RIGHT\/LEFT SHOULDER, ARM, FOREARM, ARM\" id=\"form-field-field_dcd237a-0\" name=\"form_fields[field_dcd237a]\"> <label for=\"form-field-field_dcd237a-0\">NECK PAIN, NUMBNESS, TINGLING, AND\/OR WEAKNESS THAT RADIATES OR GOES DOWN TO RIGHT\/LEFT SHOULDER, ARM, FOREARM, ARM<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_b260d32 elementor-col-33 elementor-md-50\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"NECK PAIN THAT CAUSES HEADACHES\" id=\"form-field-field_b260d32-0\" name=\"form_fields[field_b260d32]\"> <label for=\"form-field-field_b260d32-0\">NECK PAIN THAT CAUSES HEADACHES<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_aac5058 elementor-col-33 elementor-md-50\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"NECK OR SHOULDER SPASMS\" id=\"form-field-field_aac5058-0\" name=\"form_fields[field_aac5058]\"> <label for=\"form-field-field_aac5058-0\">NECK OR SHOULDER SPASMS<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_2733167 elementor-col-33 elementor-md-50\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"NECK PAIN THAT CAUSES HEADACHES\" id=\"form-field-field_2733167-0\" name=\"form_fields[field_2733167]\"> <label for=\"form-field-field_2733167-0\">NECK PAIN THAT CAUSES HEADACHES<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_a52b6c5 elementor-col-100 elementor-md-50\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"POPPING OR CLICKING SOUND\" id=\"form-field-field_a52b6c5-0\" name=\"form_fields[field_a52b6c5]\"> <label for=\"form-field-field_a52b6c5-0\">POPPING OR CLICKING SOUND<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_44ba218 elementor-col-100\">\n\t\t\t\t\t<b>Back<\/b>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_3b269bb elementor-col-33 elementor-md-50\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"UPPER, MID, OR LOW BACK PAIN\" id=\"form-field-field_3b269bb-0\" name=\"form_fields[field_3b269bb]\"> <label for=\"form-field-field_3b269bb-0\">UPPER, MID, OR LOW BACK PAIN<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_37ccd49 elementor-col-33 elementor-md-50\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"BACK SPASMS\" id=\"form-field-field_37ccd49-0\" name=\"form_fields[field_37ccd49]\"> <label for=\"form-field-field_37ccd49-0\">BACK SPASMS<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_a472335 elementor-col-100\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"BACK PAIN, NUMBNESS, TINGLING, AND\/OR WEAKNESS THAT RADIATES OR GOES TO RIGHT\/LEFT SHOULDER, ARM, FOREARM, HAND\" id=\"form-field-field_a472335-0\" name=\"form_fields[field_a472335]\"> <label for=\"form-field-field_a472335-0\">BACK PAIN, NUMBNESS, TINGLING, AND\/OR WEAKNESS THAT RADIATES OR GOES TO RIGHT\/LEFT SHOULDER, ARM, FOREARM, HAND<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_f42c4ec elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f42c4ec\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOTHER SYMPTOMS:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-md\" name=\"form_fields[field_f42c4ec]\" id=\"form-field-field_f42c4ec\" rows=\"4\" placeholder=\"massage\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button type=\"submit\" class=\"elementor-button elementor-size-md\">\n\t\t\t\t\t\t<span >\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\" elementor-button-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Submit<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Client Symptom Questionnaire<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"_links":{"self":[{"href":"https:\/\/hopemedicalgroups.com\/wp-json\/wp\/v2\/pages\/3893"}],"collection":[{"href":"https:\/\/hopemedicalgroups.com\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/hopemedicalgroups.com\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/hopemedicalgroups.com\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/hopemedicalgroups.com\/wp-json\/wp\/v2\/comments?post=3893"}],"version-history":[{"count":54,"href":"https:\/\/hopemedicalgroups.com\/wp-json\/wp\/v2\/pages\/3893\/revisions"}],"predecessor-version":[{"id":4542,"href":"https:\/\/hopemedicalgroups.com\/wp-json\/wp\/v2\/pages\/3893\/revisions\/4542"}],"wp:attachment":[{"href":"https:\/\/hopemedicalgroups.com\/wp-json\/wp\/v2\/media?parent=3893"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}