{"id":1493,"date":"2024-04-18T10:37:41","date_gmt":"2024-04-18T09:37:41","guid":{"rendered":"https:\/\/divessl.com\/ts-basic-medico\/"},"modified":"2024-04-19T12:09:03","modified_gmt":"2024-04-19T11:09:03","slug":"discover-scuba-diving","status":"publish","type":"page","link":"https:\/\/divessl.com\/en\/registration-form\/discover-scuba-diving\/","title":{"rendered":"Discover Scuba Diving"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row el_class=&#8221;box-formulario&#8221;][vc_column][vc_empty_space height=&#8221;64px&#8221;][vc_column_text css=&#8221;&#8221; el_class=&#8221;titulo-form-insc&#8221;]Registration Form[\/vc_column_text]<style id=\"wpforms-css-vars-1478\">\n\t\t\t\t#wpforms-1478 {\n\t\t\t\t\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full ts-basic wpforms-render-modern\" id=\"wpforms-1478\"><form id=\"wpforms-form-1478\" class=\"wpforms-validate wpforms-form\" data-formid=\"1478\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/en\/wp-json\/wp\/v2\/pages\/1493\" data-token=\"351b687fe4dc8afc91615b44b353da6f\" data-token-time=\"1779327294\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \" data-page=\"1\"><div id=\"wpforms-1478-field_242-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"242\"><\/div><div id=\"wpforms-1478-field_239-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"239\"><div id=\"wpforms-1478-field_239\" aria-errormessage=\"wpforms-1478-field_239-error\"><h2>Try Scuba - Basic Diver<\/h2><\/div><\/div><div id=\"wpforms-1478-field_49-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"49\"><div id=\"wpforms-1478-field_49\" aria-errormessage=\"wpforms-1478-field_49-error\"><h3>Personal information<\/h3><\/div><\/div><div id=\"wpforms-1478-field_23-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"23\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_1-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-1478-field_1\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1478-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" aria-errormessage=\"wpforms-1478-field_1-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_2-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-1478-field_2\">Surname <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1478-field_2\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][2]\" aria-errormessage=\"wpforms-1478-field_2-error\" required><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_26-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"26\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-25-25\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-1478-field_3\">Passport number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1478-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" aria-errormessage=\"wpforms-1478-field_3-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_4-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-1478-field_4\">Birthdate <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-1478-field_4\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][4][date]\" aria-errormessage=\"wpforms-1478-field_4-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_246-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"246\"><label class=\"wpforms-field-label\" for=\"wpforms-1478-field_246\">Gender <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-1478-field_246\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][246]\" required=\"required\"><option value=\"Male\"  class=\"choice-1 depth-1\"  >Male<\/option><option value=\"Female\"  class=\"choice-2 depth-1\"  >Female<\/option><option value=\"I don&#039;t want to say\"  class=\"choice-3 depth-1\"  >I don't want to say<\/option><\/select><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_27-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"27\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_31-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-1478-field_31\">Country <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-1478-field_31\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][31]\" required=\"required\"><option value=\"Afghanistan\"  class=\"choice-4 depth-1\"  >Afghanistan<\/option><option value=\"Albania\"  class=\"choice-5 depth-1\"  >Albania<\/option><option value=\"Germany\"  class=\"choice-6 depth-1\"  >Germany<\/option><option value=\"Andorra\"  class=\"choice-7 depth-1\"  >Andorra<\/option><option value=\"Angola\"  class=\"choice-8 depth-1\"  >Angola<\/option><option value=\"Anguilla\"  class=\"choice-9 depth-1\"  >Anguilla<\/option><option value=\"Antigua and Barbuda\"  class=\"choice-10 depth-1\"  >Antigua and Barbuda<\/option><option value=\"Antarctica\"  class=\"choice-11 depth-1\"  >Antarctica<\/option><option value=\"Algeria\"  class=\"choice-12 depth-1\"  >Algeria<\/option><option value=\"Argentina\"  class=\"choice-13 depth-1\"  >Argentina<\/option><option value=\"Armenia\"  class=\"choice-14 depth-1\"  >Armenia<\/option><option value=\"Aruba\"  class=\"choice-15 depth-1\"  >Aruba<\/option><option value=\"Australia\"  class=\"choice-16 depth-1\"  >Australia<\/option><option value=\"Austria\"  class=\"choice-17 depth-1\"  >Austria<\/option><option value=\"Azerbaijan\"  class=\"choice-18 depth-1\"  >Azerbaijan<\/option><option value=\"Bahamas\"  class=\"choice-19 depth-1\"  >Bahamas<\/option><option value=\"Bangladesh\"  class=\"choice-20 depth-1\"  >Bangladesh<\/option><option value=\"Barbados\"  class=\"choice-21 depth-1\"  >Barbados<\/option><option value=\"Bahrain\"  class=\"choice-22 depth-1\"  >Bahrain<\/option><option value=\"Belize\"  class=\"choice-23 depth-1\"  >Belize<\/option><option value=\"Benin\"  class=\"choice-24 depth-1\"  >Benin<\/option><option value=\"Bermuda\"  class=\"choice-25 depth-1\"  >Bermuda<\/option><option value=\"Belarus\"  class=\"choice-26 depth-1\"  >Belarus<\/option><option value=\"Bolivia, Plurinational State of\"  class=\"choice-27 depth-1\"  >Bolivia, Plurinational State of<\/option><option value=\"Bonaire, Sint Eustatius and Saba\"  class=\"choice-28 depth-1\"  >Bonaire, Sint Eustatius and Saba<\/option><option value=\"Bosnia and Herzegovina\"  class=\"choice-29 depth-1\"  >Bosnia and Herzegovina<\/option><option value=\"Botswana\"  class=\"choice-30 depth-1\"  >Botswana<\/option><option value=\"Brazil\"  class=\"choice-31 depth-1\"  >Brazil<\/option><option value=\"Brunei Darussalam\"  class=\"choice-32 depth-1\"  >Brunei Darussalam<\/option><option value=\"Bulgaria\"  class=\"choice-33 depth-1\"  >Bulgaria<\/option><option value=\"Burkina Faso\"  class=\"choice-34 depth-1\"  >Burkina Faso<\/option><option value=\"Burundi\"  class=\"choice-35 depth-1\"  >Burundi<\/option><option value=\"Bhutan\"  class=\"choice-36 depth-1\"  >Bhutan<\/option><option value=\"Belgium\"  class=\"choice-37 depth-1\"  >Belgium<\/option><option value=\"Cabo Verde\"  class=\"choice-38 depth-1\"  >Cabo Verde<\/option><option value=\"Cambodia\"  class=\"choice-39 depth-1\"  >Cambodia<\/option><option value=\"Cameroon\"  class=\"choice-40 depth-1\"  >Cameroon<\/option><option value=\"Canada\"  class=\"choice-41 depth-1\"  >Canada<\/option><option value=\"Chad\"  class=\"choice-42 depth-1\"  >Chad<\/option><option value=\"Xile\"  class=\"choice-43 depth-1\"  >Xile<\/option><option value=\"China\"  class=\"choice-44 depth-1\"  >China<\/option><option value=\"Cyprus\"  class=\"choice-45 depth-1\"  >Cyprus<\/option><option value=\"Colombia\"  class=\"choice-46 depth-1\"  >Colombia<\/option><option value=\"Comoros\"  class=\"choice-47 depth-1\"  >Comoros<\/option><option value=\"Congo\"  class=\"choice-48 depth-1\"  >Congo<\/option><option value=\"Congo (Democratic Republic of)\"  class=\"choice-49 depth-1\"  >Congo (Democratic Republic of)<\/option><option value=\"Korea (Republic of)\"  class=\"choice-50 depth-1\"  >Korea (Republic of)<\/option><option value=\"North Korea\"  class=\"choice-51 depth-1\"  >North Korea<\/option><option value=\"Costa Rica\"  class=\"choice-52 depth-1\"  >Costa Rica<\/option><option value=\"Ivory Coast\"  class=\"choice-53 depth-1\"  >Ivory Coast<\/option><option value=\"Croatia\"  class=\"choice-54 depth-1\"  >Croatia<\/option><option value=\"Cuba\"  class=\"choice-55 depth-1\"  >Cuba<\/option><option value=\"Cura\u00e7ao\"  class=\"choice-56 depth-1\"  >Cura\u00e7ao<\/option><option value=\"Denmark\"  class=\"choice-57 depth-1\"  >Denmark<\/option><option value=\"Dominica\"  class=\"choice-58 depth-1\"  >Dominica<\/option><option value=\"Ecuador\"  class=\"choice-59 depth-1\"  >Ecuador<\/option><option value=\"Egypt\"  class=\"choice-60 depth-1\"  >Egypt<\/option><option value=\"El Salvador\"  class=\"choice-61 depth-1\"  >El Salvador<\/option><option value=\"United Arab Emirates\"  class=\"choice-62 depth-1\"  >United Arab Emirates<\/option><option value=\"Eritrea\"  class=\"choice-63 depth-1\"  >Eritrea<\/option><option value=\"Slovakia\"  class=\"choice-64 depth-1\"  >Slovakia<\/option><option value=\"Slovenia\"  class=\"choice-65 depth-1\"  >Slovenia<\/option><option value=\"Spain\"  selected='selected' class=\"choice-66 depth-1\"  >Spain<\/option><option value=\"Holy See (Vatican City State)\"  class=\"choice-67 depth-1\"  >Holy See (Vatican City State)<\/option><option value=\"United States of America\"  class=\"choice-68 depth-1\"  >United States of America<\/option><option value=\"Estonia\"  class=\"choice-69 depth-1\"  >Estonia<\/option><option value=\"Ethiopia\"  class=\"choice-70 depth-1\"  >Ethiopia<\/option><option value=\"Russian Federation\"  class=\"choice-71 depth-1\"  >Russian Federation<\/option><option value=\"Fiji\"  class=\"choice-72 depth-1\"  >Fiji<\/option><option value=\"Philippines\"  class=\"choice-73 depth-1\"  >Philippines<\/option><option value=\"Finland\"  class=\"choice-74 depth-1\"  >Finland<\/option><option value=\"France\"  class=\"choice-75 depth-1\"  >France<\/option><option value=\"Gabon\"  class=\"choice-76 depth-1\"  >Gabon<\/option><option value=\"Gambia\"  class=\"choice-77 depth-1\"  >Gambia<\/option><option value=\"Georgia\"  class=\"choice-78 depth-1\"  >Georgia<\/option><option value=\"Ghana\"  class=\"choice-79 depth-1\"  >Ghana<\/option><option value=\"Gibraltar\"  class=\"choice-80 depth-1\"  >Gibraltar<\/option><option value=\"Grenada\"  class=\"choice-81 depth-1\"  >Grenada<\/option><option value=\"Greece\"  class=\"choice-82 depth-1\"  >Greece<\/option><option value=\"Greenland\"  class=\"choice-83 depth-1\"  >Greenland<\/option><option value=\"Guadeloupe\"  class=\"choice-84 depth-1\"  >Guadeloupe<\/option><option value=\"Guam\"  class=\"choice-85 depth-1\"  >Guam<\/option><option value=\"Guatemala\"  class=\"choice-86 depth-1\"  >Guatemala<\/option><option value=\"French Guiana\"  class=\"choice-87 depth-1\"  >French Guiana<\/option><option value=\"Guernsey\"  class=\"choice-88 depth-1\"  >Guernsey<\/option><option value=\"Guinea\"  class=\"choice-89 depth-1\"  >Guinea<\/option><option value=\"Guinea Equatorial\"  class=\"choice-90 depth-1\"  >Guinea Equatorial<\/option><option value=\"Guinea-Bissau\"  class=\"choice-91 depth-1\"  >Guinea-Bissau<\/option><option value=\"Guyana\"  class=\"choice-92 depth-1\"  >Guyana<\/option><option value=\"Haiti\"  class=\"choice-93 depth-1\"  >Haiti<\/option><option value=\"Honduras\"  class=\"choice-94 depth-1\"  >Honduras<\/option><option value=\"Hong Kong\"  class=\"choice-95 depth-1\"  >Hong Kong<\/option><option value=\"Hungary\"  class=\"choice-96 depth-1\"  >Hungary<\/option><option value=\"India\"  class=\"choice-97 depth-1\"  >India<\/option><option value=\"Indonesia\"  class=\"choice-98 depth-1\"  >Indonesia<\/option><option value=\"Iraq\"  class=\"choice-99 depth-1\"  >Iraq<\/option><option value=\"Ireland (Republic of)\"  class=\"choice-100 depth-1\"  >Ireland (Republic of)<\/option><option value=\"Islamic Republic of Iran\"  class=\"choice-101 depth-1\"  >Islamic Republic of Iran<\/option><option value=\"Bouvet Island\"  class=\"choice-102 depth-1\"  >Bouvet Island<\/option><option value=\"Isle of Man\"  class=\"choice-103 depth-1\"  >Isle of Man<\/option><option value=\"Isle of Man\"  class=\"choice-104 depth-1\"  >Isle of Man<\/option><option value=\"Christmas Island\"  class=\"choice-105 depth-1\"  >Christmas Island<\/option><option value=\"Iceland\"  class=\"choice-106 depth-1\"  >Iceland<\/option><option value=\"Cocos Islands\"  class=\"choice-107 depth-1\"  >Cocos Islands<\/option><option value=\"Cocos Islands\"  class=\"choice-108 depth-1\"  >Cocos Islands<\/option><option value=\"Cook Islands\"  class=\"choice-109 depth-1\"  >Cook Islands<\/option><option value=\"Faroe Islands\"  class=\"choice-110 depth-1\"  >Faroe Islands<\/option><option value=\"Heard and McDonald Islands\"  class=\"choice-111 depth-1\"  >Heard and McDonald Islands<\/option><option value=\"Falkland Islands (Malvinas)\"  class=\"choice-112 depth-1\"  >Falkland Islands (Malvinas)<\/option><option value=\"Northern Mariana Islands\"  class=\"choice-113 depth-1\"  >Northern Mariana Islands<\/option><option value=\"Marshall Islands\"  class=\"choice-114 depth-1\"  >Marshall Islands<\/option><option value=\"Solomon Islands\"  class=\"choice-115 depth-1\"  >Solomon Islands<\/option><option value=\"Turks and Caicos Islands\"  class=\"choice-116 depth-1\"  >Turks and Caicos Islands<\/option><option value=\"United States Minor Outlying Islands\"  class=\"choice-117 depth-1\"  >United States Minor Outlying Islands<\/option><option value=\"US Virgin Islands\"  class=\"choice-118 depth-1\"  >US Virgin Islands<\/option><option value=\"British Virgin Islands\"  class=\"choice-119 depth-1\"  >British Virgin Islands<\/option><option value=\"South Georgia and South Sandwich Islands\"  class=\"choice-120 depth-1\"  >South Georgia and South Sandwich Islands<\/option><option value=\"\u00c5land Islands\"  class=\"choice-121 depth-1\"  >\u00c5land Islands<\/option><option value=\"Israel\"  class=\"choice-122 depth-1\"  >Israel<\/option><option value=\"Italy\"  class=\"choice-123 depth-1\"  >Italy<\/option><option value=\"Jamaica\"  class=\"choice-124 depth-1\"  >Jamaica<\/option><option value=\"Japan\"  class=\"choice-125 depth-1\"  >Japan<\/option><option value=\"Jersey\"  class=\"choice-126 depth-1\"  >Jersey<\/option><option value=\"Jordan\"  class=\"choice-127 depth-1\"  >Jordan<\/option><option value=\"Qatar\"  class=\"choice-128 depth-1\"  >Qatar<\/option><option value=\"Kazakhstan\"  class=\"choice-129 depth-1\"  >Kazakhstan<\/option><option value=\"Kenya\"  class=\"choice-130 depth-1\"  >Kenya<\/option><option value=\"Kyrgyzstan\"  class=\"choice-131 depth-1\"  >Kyrgyzstan<\/option><option value=\"Kiribati\"  class=\"choice-132 depth-1\"  >Kiribati<\/option><option value=\"Kosovo\"  class=\"choice-133 depth-1\"  >Kosovo<\/option><option value=\"Kuwait\"  class=\"choice-134 depth-1\"  >Kuwait<\/option><option value=\"Lesotho\"  class=\"choice-135 depth-1\"  >Lesotho<\/option><option value=\"Latvia\"  class=\"choice-136 depth-1\"  >Latvia<\/option><option value=\"Liberia\"  class=\"choice-137 depth-1\"  >Liberia<\/option><option value=\"Libya\"  class=\"choice-138 depth-1\"  >Libya<\/option><option value=\"Liechtenstein\"  class=\"choice-139 depth-1\"  >Liechtenstein<\/option><option value=\"Lithuania\"  class=\"choice-140 depth-1\"  >Lithuania<\/option><option value=\"Luxembourg\"  class=\"choice-141 depth-1\"  >Luxembourg<\/option><option value=\"Lebanon\"  class=\"choice-142 depth-1\"  >Lebanon<\/option><option value=\"Macau\"  class=\"choice-143 depth-1\"  >Macau<\/option><option value=\"North Macedonia (Republic of)\"  class=\"choice-144 depth-1\"  >North Macedonia (Republic of)<\/option><option value=\" Madagascar\"  class=\"choice-145 depth-1\"  >Madagascar<\/option><option value=\"Malaysia\"  class=\"choice-146 depth-1\"  >Malaysia<\/option><option value=\"Malawi\"  class=\"choice-147 depth-1\"  >Malawi<\/option><option value=\"Maldives\"  class=\"choice-148 depth-1\"  >Maldives<\/option><option value=\"Mali\"  class=\"choice-149 depth-1\"  >Mali<\/option><option value=\"Malta\"  class=\"choice-150 depth-1\"  >Malta<\/option><option value=\"Morocco\"  class=\"choice-151 depth-1\"  >Morocco<\/option><option value=\"Martinique\"  class=\"choice-152 depth-1\"  >Martinique<\/option><option value=\"Mauritius\"  class=\"choice-153 depth-1\"  >Mauritius<\/option><option value=\"Mauritania\"  class=\"choice-154 depth-1\"  >Mauritania<\/option><option value=\"Mayotte\"  class=\"choice-155 depth-1\"  >Mayotte<\/option><option value=\"Micronesia, Federated States of\"  class=\"choice-156 depth-1\"  >Micronesia, Federated States of<\/option><option value=\"Moldova\"  class=\"choice-157 depth-1\"  >Moldova<\/option><option value=\"Mongolia\"  class=\"choice-158 depth-1\"  >Mongolia<\/option><option value=\"Montenegro\"  class=\"choice-159 depth-1\"  >Montenegro<\/option><option value=\"Montserrat\"  class=\"choice-160 depth-1\"  >Montserrat<\/option><option value=\"Mozambique\"  class=\"choice-161 depth-1\"  >Mozambique<\/option><option value=\"Myanmar\"  class=\"choice-162 depth-1\"  >Myanmar<\/option><option value=\"Mexico\"  class=\"choice-163 depth-1\"  >Mexico<\/option><option value=\"Monaco\"  class=\"choice-164 depth-1\"  >Monaco<\/option><option value=\"Namibia\"  class=\"choice-165 depth-1\"  >Namibia<\/option><option value=\"Nauru\"  class=\"choice-166 depth-1\"  >Nauru<\/option><option value=\"Nepal\"  class=\"choice-167 depth-1\"  >Nepal<\/option><option value=\"Nicaragua\"  class=\"choice-168 depth-1\"  >Nicaragua<\/option><option value=\"Nigeria\"  class=\"choice-169 depth-1\"  >Nigeria<\/option><option value=\"Niue\"  class=\"choice-170 depth-1\"  >Niue<\/option><option value=\"Norway\"  class=\"choice-171 depth-1\"  >Norway<\/option><option value=\"New Caledonia\"  class=\"choice-172 depth-1\"  >New Caledonia<\/option><option value=\"New Zealand\"  class=\"choice-173 depth-1\"  >New Zealand<\/option><option value=\"Niger\"  class=\"choice-174 depth-1\"  >Niger<\/option><option value=\"Oman\"  class=\"choice-175 depth-1\"  >Oman<\/option><option value=\"Pakistan\"  class=\"choice-176 depth-1\"  >Pakistan<\/option><option value=\"Palau\"  class=\"choice-177 depth-1\"  >Palau<\/option><option value=\"Palestine (State of)\"  class=\"choice-178 depth-1\"  >Palestine (State of)<\/option><option value=\"Panama\"  class=\"choice-179 depth-1\"  >Panama<\/option><option value=\"Papua New Guinea\"  class=\"choice-180 depth-1\"  >Papua New Guinea<\/option><option value=\"Paraguay\"  class=\"choice-181 depth-1\"  >Paraguay<\/option><option value=\"Netherlands\"  class=\"choice-182 depth-1\"  >Netherlands<\/option><option value=\"Peru\"  class=\"choice-183 depth-1\"  >Peru<\/option><option value=\"Pitcairn\"  class=\"choice-184 depth-1\"  >Pitcairn<\/option><option value=\"French Polynesia\"  class=\"choice-185 depth-1\"  >French Polynesia<\/option><option value=\"Poland\"  class=\"choice-186 depth-1\"  >Poland<\/option><option value=\"Portugal\"  class=\"choice-187 depth-1\"  >Portugal<\/option><option value=\"Puerto Rico\"  class=\"choice-188 depth-1\"  >Puerto Rico<\/option><option value=\"United Kingdom of Great Britain and Northern Ireland\"  class=\"choice-189 depth-1\"  >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"Central African Republic\"  class=\"choice-190 depth-1\"  >Central African Republic<\/option><option value=\"Chech Republic\"  class=\"choice-191 depth-1\"  >Chech Republic<\/option><option value=\"Dominican Republic\"  class=\"choice-192 depth-1\"  >Dominican Republic<\/option><option value=\"Lao People&#039;s Democratic Republic\"  class=\"choice-193 depth-1\"  >Lao People's Democratic Republic<\/option><option value=\"Syrian Arab Republic\"  class=\"choice-194 depth-1\"  >Syrian Arab Republic<\/option><option value=\"R\u00e9union\"  class=\"choice-195 depth-1\"  >R\u00e9union<\/option><option value=\"Rwanda\"  class=\"choice-196 depth-1\"  >Rwanda<\/option><option value=\"Romania\"  class=\"choice-197 depth-1\"  >Romania<\/option><option value=\"Saint Kitts and Nevis\"  class=\"choice-198 depth-1\"  >Saint Kitts and Nevis<\/option><option value=\"Samoa\"  class=\"choice-199 depth-1\"  >Samoa<\/option><option value=\"American Samoa\"  class=\"choice-200 depth-1\"  >American Samoa<\/option><option value=\"Saint Barth\u00e9lemy\"  class=\"choice-201 depth-1\"  >Saint Barth\u00e9lemy<\/option><option value=\"San Marino\"  class=\"choice-202 depth-1\"  >San Marino<\/option><option value=\"Saint Martin (French part)\"  class=\"choice-203 depth-1\"  >Saint Martin (French part)<\/option><option value=\"Sint Maarten (Dutch part)\"  class=\"choice-204 depth-1\"  >Sint Maarten (Dutch part)<\/option><option value=\"Saint Pierre and Miquelon\"  class=\"choice-205 depth-1\"  >Saint Pierre and Miquelon<\/option><option value=\"St. Vincent and the Grenadines\"  class=\"choice-206 depth-1\"  >St. Vincent and the Grenadines<\/option><option value=\"Saint Helena, Ascension and Tristan da Cunha\"  class=\"choice-207 depth-1\"  >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"St. Lucia\"  class=\"choice-208 depth-1\"  >St. Lucia<\/option><option value=\"Sao Tome and Principe\"  class=\"choice-209 depth-1\"  >Sao Tome and Principe<\/option><option value=\"Saudi Arabia\"  class=\"choice-210 depth-1\"  >Saudi Arabia<\/option><option value=\"Senegal\"  class=\"choice-211 depth-1\"  >Senegal<\/option><option value=\"Serbia\"  class=\"choice-212 depth-1\"  >Serbia<\/option><option value=\"Seychelles\"  class=\"choice-213 depth-1\"  >Seychelles<\/option><option value=\"Sierra Leone\"  class=\"choice-214 depth-1\"  >Sierra Leone<\/option><option value=\"Singapore\"  class=\"choice-215 depth-1\"  >Singapore<\/option><option value=\"Somalia\"  class=\"choice-216 depth-1\"  >Somalia<\/option><option value=\"Sri Lanka\"  class=\"choice-217 depth-1\"  >Sri Lanka<\/option><option value=\"Swaziland (Kingdom of)\"  class=\"choice-218 depth-1\"  >Swaziland (Kingdom of)<\/option><option value=\"South Africa\"  class=\"choice-219 depth-1\"  >South Africa<\/option><option value=\"Sudan\"  class=\"choice-220 depth-1\"  >Sudan<\/option><option value=\"South Sudan\"  class=\"choice-221 depth-1\"  >South Sudan<\/option><option value=\"Sweden\"  class=\"choice-222 depth-1\"  >Sweden<\/option><option value=\"Switzerland\"  class=\"choice-223 depth-1\"  >Switzerland<\/option><option value=\"Surinam\"  class=\"choice-224 depth-1\"  >Surinam<\/option><option value=\"Svalbard and Jan Mayen\"  class=\"choice-225 depth-1\"  >Svalbard and Jan Mayen<\/option><option value=\"Occidental Sahara\"  class=\"choice-226 depth-1\"  >Occidental Sahara<\/option><option value=\"Thailand\"  class=\"choice-227 depth-1\"  >Thailand<\/option><option value=\"Taiwan, Republic of China\"  class=\"choice-228 depth-1\"  >Taiwan, Republic of China<\/option><option value=\"Tanzania (United Republic of)\"  class=\"choice-229 depth-1\"  >Tanzania (United Republic of)<\/option><option value=\"Tajikistan\"  class=\"choice-230 depth-1\"  >Tajikistan<\/option><option value=\"British Indian Ocean Territory\"  class=\"choice-231 depth-1\"  >British Indian Ocean Territory<\/option><option value=\"French Southern and Antarctic Lands\"  class=\"choice-232 depth-1\"  >French Southern and Antarctic Lands<\/option><option value=\"Timor-Leste\"  class=\"choice-233 depth-1\"  >Timor-Leste<\/option><option value=\"Togo\"  class=\"choice-234 depth-1\"  >Togo<\/option><option value=\"Tokelau\"  class=\"choice-235 depth-1\"  >Tokelau<\/option><option value=\"Tonga\"  class=\"choice-236 depth-1\"  >Tonga<\/option><option value=\"Trinidad and Tobago\"  class=\"choice-237 depth-1\"  >Trinidad and Tobago<\/option><option value=\"Turkmenistan\"  class=\"choice-238 depth-1\"  >Turkmenistan<\/option><option value=\"Tuvalu\"  class=\"choice-239 depth-1\"  >Tuvalu<\/option><option value=\"Tunisia\"  class=\"choice-240 depth-1\"  >Tunisia<\/option><option value=\"T\u00fcrkiye\"  class=\"choice-241 depth-1\"  >T\u00fcrkiye<\/option><option value=\"Ukraine\"  class=\"choice-242 depth-1\"  >Ukraine<\/option><option value=\"Uganda\"  class=\"choice-243 depth-1\"  >Uganda<\/option><option value=\"Uruguay\"  class=\"choice-244 depth-1\"  >Uruguay<\/option><option value=\"Uzbekistan\"  class=\"choice-245 depth-1\"  >Uzbekistan<\/option><option value=\"Vanuatu\"  class=\"choice-246 depth-1\"  >Vanuatu<\/option><option value=\"Venezuela (Bolivarian Republic of)\"  class=\"choice-247 depth-1\"  >Venezuela (Bolivarian Republic of)<\/option><option value=\"Vietnam\"  class=\"choice-248 depth-1\"  >Vietnam<\/option><option value=\"Wallis and Futuna\"  class=\"choice-249 depth-1\"  >Wallis and Futuna<\/option><option value=\"Yemen\"  class=\"choice-250 depth-1\"  >Yemen<\/option><option value=\"Djibouti\"  class=\"choice-251 depth-1\"  >Djibouti<\/option><option value=\"Zambia\"  class=\"choice-252 depth-1\"  >Zambia<\/option><option value=\"Zimbabwe\"  class=\"choice-253 depth-1\"  >Zimbabwe<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_5-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-1478-field_5\">Postcode <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1478-field_5\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][5]\" aria-errormessage=\"wpforms-1478-field_5-error\" required><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_28-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"28\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_33-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-1478-field_33\">Phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-1478-field_33\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][33]\" aria-label=\"Phone\" aria-errormessage=\"wpforms-1478-field_33-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_6-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-1478-field_6\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-1478-field_6\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][6]\" spellcheck=\"false\" aria-errormessage=\"wpforms-1478-field_6-error\" required><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_240-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"240\"><div id=\"wpforms-1478-field_240\" aria-errormessage=\"wpforms-1478-field_240-error\"><p><b>Do you want us to tag you in your photos\/videos on social media?<\/b><\/p><\/div><\/div><div id=\"wpforms-1478-field_29-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"29\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-1478-field_8\">Instagram<\/label><input type=\"text\" id=\"wpforms-1478-field_8\" class=\"wpforms-field-medium\" name=\"wpforms[fields][8]\" placeholder=\"@\" aria-errormessage=\"wpforms-1478-field_8-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-1478-field_9\">TikTok<\/label><input type=\"text\" id=\"wpforms-1478-field_9\" class=\"wpforms-field-medium\" name=\"wpforms[fields][9]\" placeholder=\"@\" aria-errormessage=\"wpforms-1478-field_9-error\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_50-container\" class=\"wpforms-field wpforms-field-html txt-red margin-top-bg\" data-field-id=\"50\"><div id=\"wpforms-1478-field_50\" aria-errormessage=\"wpforms-1478-field_50-error\"><h3>In case of under 18 years old, father\/mother\/legal guardian must fill in:<\/h3><\/div><\/div><div id=\"wpforms-1478-field_34-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"34\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_10-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-trigger\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-1478-field_10\">Name<\/label><input type=\"text\" id=\"wpforms-1478-field_10\" class=\"wpforms-field-medium\" name=\"wpforms[fields][10]\" aria-errormessage=\"wpforms-1478-field_10-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-1478-field_11\">Surname<\/label><input type=\"text\" id=\"wpforms-1478-field_11\" class=\"wpforms-field-medium\" name=\"wpforms[fields][11]\" aria-errormessage=\"wpforms-1478-field_11-error\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_35-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"35\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-1478-field_12\">Passport number<\/label><input type=\"text\" id=\"wpforms-1478-field_12\" class=\"wpforms-field-medium\" name=\"wpforms[fields][12]\" aria-errormessage=\"wpforms-1478-field_12-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_37-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"37\"><label class=\"wpforms-field-label\" for=\"wpforms-1478-field_37\">Phone<\/label><input type=\"tel\" id=\"wpforms-1478-field_37\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][37]\" aria-label=\"Phone\" aria-errormessage=\"wpforms-1478-field_37-error\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_51-container\" class=\"wpforms-field wpforms-field-html margin-top-bg\" data-field-id=\"51\"><div id=\"wpforms-1478-field_51\" aria-errormessage=\"wpforms-1478-field_51-error\"><h3>Information for the activity\n<\/h3><\/div><\/div><div id=\"wpforms-1478-field_36-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"36\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_13-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-1478-field_13\">Entry date <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-1478-field_13\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][13][date]\" aria-errormessage=\"wpforms-1478-field_13-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_14-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-1478-field_14\">Departure date <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-1478-field_14\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"1\" data-disable-todays-date=\"0\" data-input=\"true\" name=\"wpforms[fields][14][date]\" aria-errormessage=\"wpforms-1478-field_14-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_15-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-1478-field_15\">Accommodation <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1478-field_15\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][15]\" aria-errormessage=\"wpforms-1478-field_15-error\" required><\/div><div id=\"wpforms-1478-field_52-container\" class=\"wpforms-field wpforms-field-html margin-top-bg\" data-field-id=\"52\"><div id=\"wpforms-1478-field_52\" aria-errormessage=\"wpforms-1478-field_52-error\"><p>In case of emergency:<\/p><\/div><\/div><div id=\"wpforms-1478-field_38-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"38\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-33-33-33\"><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-1478-field_16-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-1478-field_16\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1478-field_16\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][16]\" aria-errormessage=\"wpforms-1478-field_16-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-1478-field_17-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-1478-field_17\">Surname <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1478-field_17\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][17]\" aria-errormessage=\"wpforms-1478-field_17-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-1478-field_40-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"40\"><label class=\"wpforms-field-label\" for=\"wpforms-1478-field_40\">Phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-1478-field_40\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][40]\" aria-label=\"Phone\" aria-errormessage=\"wpforms-1478-field_40-error\" required><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_53-container\" class=\"wpforms-field wpforms-field-html margin-top-bg\" data-field-id=\"53\"><div id=\"wpforms-1478-field_53\" aria-errormessage=\"wpforms-1478-field_53-error\"><p>Information required to prepare your scuba diving equipment<\/p><\/div><\/div><div id=\"wpforms-1478-field_39-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"39\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-33-33-33\"><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-1478-field_18-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-1478-field_18\">Height (cm) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-1478-field_18\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][18]\" step=\"any\" aria-errormessage=\"wpforms-1478-field_18-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-1478-field_19-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-1478-field_19\">Weight (kg) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-1478-field_19\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][19]\" step=\"any\" aria-errormessage=\"wpforms-1478-field_19-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-1478-field_20-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-1478-field_20\">Shoe size (EU) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-1478-field_20\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][20]\" step=\"any\" aria-errormessage=\"wpforms-1478-field_20-error\" required><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_57-container\" class=\"wpforms-field wpforms-field-html margin-top-bg\" data-field-id=\"57\"><div id=\"wpforms-1478-field_57\" aria-errormessage=\"wpforms-1478-field_57-error\"><h3>I declare that:<\/h3>\n<ol>\n<li><p>Scuba School Lanzarote informs me that, according to Spanish law, it is mandatory to fill out the medical questionnaire attached to this form. I declare that all information provided is truthful and understand that I accept responsibility for any consequences resulting from inaccurate responses or failure to disclose relevant information.<\/p><\/li>\n<li><p>I am fully responsible for the custody of rental equipment owned by the school and must return it in case of loss or theft during the contracted activity.<\/p><\/li>\n<li><p>I confirm that I have been informed about the inherent risks of diving and commit to following the instructions provided by the instructor in the pre-dive briefing.<\/p><\/li>\n<li><p>I am informed that flying within 18 hours after the end of the dive is not allowed.<\/p>\n<p>At Scuba School Lanzarote, legally represented by Luis Duque Garcia with ID number 40981368Z, we process the provided information to provide the requested services and handle billing. The data will be retained as long as the commercial relationship lasts or as required by legal obligations. Data will not be disclosed to third parties except when legally required.<\/p>\n<p>By signing this document, you authorize Scuba School Lanzarote to use your data to offer new services, promotions, and communications related to diving. You have the right to confirm whether we are processing your personal data correctly, access your data, correct inaccuracies, or request deletion when data is no longer necessary.<\/p>\n<p>During activities, photographs or images may be taken for promotional, informative, or educational purposes related to diving and the school. By signing this document, I consent to the creation and processing of these images.<\/p>\n<\/li>\n<\/ol><\/div><\/div><div id=\"wpforms-1478-field_41-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"41\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_45-container\" class=\"wpforms-field wpforms-field-signature margin-top-bg\" data-field-id=\"45\"><label class=\"wpforms-field-label\" for=\"wpforms-1478-field_45\">Signature <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1478-field_45\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][45]\" autocomplete=\"off\" inputmode=\"none\" aria-errormessage=\"wpforms-1478-field_45-error\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-1478-field_45-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Clear Signature\" tabindex=\"0\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"1em\" height=\"1em\" preserveAspectRatio=\"xMidYMid meet\" viewBox=\"0 0 1536 1536\">\n\t\t\t\t\t<path fill=\"var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )\" d=\"M1149 994q0-26-19-45L949 768l181-181q19-19 19-45q0-27-19-46l-90-90q-19-19-46-19q-26 0-45 19L768 587L587 406q-19-19-45-19q-27 0-46 19l-90 90q-19 19-19 46q0 26 19 45l181 181l-181 181q-19 19-19 45q0 27 19 46l90 90q19 19 46 19q26 0 45-19l181-181l181 181q19 19 45 19q27 0 46-19l90-90q19-19 19-46zm387-226q0 209-103 385.5T1153.5 1433T768 1536t-385.5-103T103 1153.5T0 768t103-385.5T382.5 103T768 0t385.5 103T1433 382.5T1536 768z\"\/>\n\t\t\t\t<\/svg>\n\t\t\t\t<div class=\"wpforms-signature-clear-caption\">Clear Signature<\/div>\n\t\t\t<\/div><\/div><\/div><div id=\"wpforms-1478-field_21-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-1478-field_21\">Date <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-1478-field_21\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"1\" data-disable-todays-date=\"0\" data-input=\"true\" name=\"wpforms[fields][21][date]\" aria-errormessage=\"wpforms-1478-field_21-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_46-container\" class=\"wpforms-field wpforms-field-signature margin-top-bg wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"46\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1478-field_46\">Authorized signature <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1478-field_46\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][46]\" autocomplete=\"off\" inputmode=\"none\" aria-errormessage=\"wpforms-1478-field_46-error\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-1478-field_46-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Clear Signature\" tabindex=\"0\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"1em\" height=\"1em\" preserveAspectRatio=\"xMidYMid meet\" viewBox=\"0 0 1536 1536\">\n\t\t\t\t\t<path fill=\"var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )\" d=\"M1149 994q0-26-19-45L949 768l181-181q19-19 19-45q0-27-19-46l-90-90q-19-19-46-19q-26 0-45 19L768 587L587 406q-19-19-45-19q-27 0-46 19l-90 90q-19 19-19 46q0 26 19 45l181 181l-181 181q-19 19-19 45q0 27 19 46l90 90q19 19 46 19q26 0 45-19l181-181l181 181q19 19 45 19q27 0 46-19l90-90q19-19 19-46zm387-226q0 209-103 385.5T1153.5 1433T768 1536t-385.5-103T103 1153.5T0 768t103-385.5T382.5 103T768 0t385.5 103T1433 382.5T1536 768z\"\/>\n\t\t\t\t<\/svg>\n\t\t\t\t<div class=\"wpforms-signature-clear-caption\">Clear Signature<\/div>\n\t\t\t<\/div><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_241-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"241\"><div class=\"wpforms-clear wpforms-pagebreak-right\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"1\" data-formid=\"1478\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2 last \" data-page=\"2\" style=\"display:none;\"><div id=\"wpforms-1478-field_70-container\" class=\"wpforms-field wpforms-field-html margin-top-bg\" data-field-id=\"70\"><div id=\"wpforms-1478-field_70\" aria-errormessage=\"wpforms-1478-field_70-error\"><h1>Diver Medical<\/h1><h2>Participant Questionnaire<\/h2><\/div><\/div><div id=\"wpforms-1478-field_71-container\" class=\"wpforms-field wpforms-field-html margin-top-bg\" data-field-id=\"71\"><div id=\"wpforms-1478-field_71\" aria-errormessage=\"wpforms-1478-field_71-error\"><p>Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation.<\/p>\n<p>If you have any concerns about your diving fitness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and\/ or dive activities. References to \"diving\" on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.<\/p>\n<br \/>\n<\/div><\/div><div id=\"wpforms-1478-field_115-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"115\"><div id=\"wpforms-1478-field_115\" aria-errormessage=\"wpforms-1478-field_115-error\"><h3>Directions<\/h3>\n<p>Complete this questionnaire as a prerequisite to a recreational scuba diving or freediving course.<\/p>\n<p><b>Note:<\/b>  If you are pregnant, or attempting to become pregnant, do not dive.<\/p><\/div><\/div><div id=\"wpforms-1478-field_72-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"72\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_74-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"74\"><div id=\"wpforms-1478-field_74\" aria-errormessage=\"wpforms-1478-field_74-error\"><span class=\"numero-preg\">1<\/span><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_76-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"76\"><div id=\"wpforms-1478-field_76\" aria-errormessage=\"wpforms-1478-field_76-error\"><p>I have had problems with my lungs, breathing, heart and\/or blood affecting my normal physical or mental performance.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_77-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-trigger\" data-field-id=\"77\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">I have had problems with my lungs, breathing, heart and\/or blood affecting my normal physical or mental performance. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_77\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_77_1\" name=\"wpforms[fields][77]\" value=\"Yes\" aria-errormessage=\"wpforms-1478-field_77_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_77_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_77_2\" name=\"wpforms[fields][77]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_77_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_77_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_134-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"134\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_136-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"136\" style=\"display:none;\"><div id=\"wpforms-1478-field_136\" aria-errormessage=\"wpforms-1478-field_136-error\"><p>Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and\/or chronic lung disease.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_137-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"137\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and\/or chronic lung disease. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_137\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_137_1\" name=\"wpforms[fields][137]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_137_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_137_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_137_2\" name=\"wpforms[fields][137]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_137_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_137_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_138-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"138\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_139-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"139\" style=\"display:none;\"><div id=\"wpforms-1478-field_139\" aria-errormessage=\"wpforms-1478-field_139-error\"><p>Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity\/exercise.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_140-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"140\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity\/exercise. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_140\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_140_1\" name=\"wpforms[fields][140]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_140_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_140_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_140_2\" name=\"wpforms[fields][140]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_140_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_140_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_141-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"141\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_142-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"142\" style=\"display:none;\"><div id=\"wpforms-1478-field_142\" aria-errormessage=\"wpforms-1478-field_142-error\"><p>A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_143-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"143\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_143\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_143_1\" name=\"wpforms[fields][143]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_143_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_143_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_143_2\" name=\"wpforms[fields][143]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_143_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_143_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_144-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"144\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_145-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"145\" style=\"display:none;\"><div id=\"wpforms-1478-field_145\" aria-errormessage=\"wpforms-1478-field_145-error\"><p>Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_146-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"146\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_146\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_146_1\" name=\"wpforms[fields][146]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_146_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_146_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_146_2\" name=\"wpforms[fields][146]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_146_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_146_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_147-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"147\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_148-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"148\" style=\"display:none;\"><div id=\"wpforms-1478-field_148\" aria-errormessage=\"wpforms-1478-field_148-error\"><p>Symptoms affecting my lungs, breathing, heart and\/or blood in the last 30 days that impair my physical or mental performance.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_149-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"149\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Symptoms affecting my lungs, breathing, heart and\/or blood in the last 30 days that impair my physical or mental performance. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_149\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_149_1\" name=\"wpforms[fields][149]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_149_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_149_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_149_2\" name=\"wpforms[fields][149]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_149_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_149_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_79-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"79\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_80-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"80\"><div id=\"wpforms-1478-field_80\" aria-errormessage=\"wpforms-1478-field_80-error\"><span class=\"numero-preg\">2<\/span><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_81-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"81\"><div id=\"wpforms-1478-field_81\" aria-errormessage=\"wpforms-1478-field_81-error\"><p>I am over 45 years of age.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_82-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-trigger\" data-field-id=\"82\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">I am over 45 years of age. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_82\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_82_1\" name=\"wpforms[fields][82]\" value=\"Yes\" aria-errormessage=\"wpforms-1478-field_82_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_82_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_82_2\" name=\"wpforms[fields][82]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_82_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_82_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_150-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"150\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_151-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"151\" style=\"display:none;\"><div id=\"wpforms-1478-field_151\" aria-errormessage=\"wpforms-1478-field_151-error\"><p>I currently smoke or inhale nicotine by other means.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_152-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"152\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">I currently smoke or inhale nicotine by other means. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_152\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_152_1\" name=\"wpforms[fields][152]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_152_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_152_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_152_2\" name=\"wpforms[fields][152]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_152_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_152_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_153-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"153\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_154-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"154\" style=\"display:none;\"><div id=\"wpforms-1478-field_154\" aria-errormessage=\"wpforms-1478-field_154-error\"><p>I have a high cholesterol level.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_155-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"155\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">I have a high cholesterol level. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_155\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_155_1\" name=\"wpforms[fields][155]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_155_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_155_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_155_2\" name=\"wpforms[fields][155]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_155_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_155_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_156-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"156\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_157-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"157\" style=\"display:none;\"><div id=\"wpforms-1478-field_157\" aria-errormessage=\"wpforms-1478-field_157-error\"><p>I have high blood pressure.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_158-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"158\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">I have high blood pressure. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_158\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_158_1\" name=\"wpforms[fields][158]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_158_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_158_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_158_2\" name=\"wpforms[fields][158]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_158_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_158_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_159-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"159\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_160-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"160\" style=\"display:none;\"><div id=\"wpforms-1478-field_160\" aria-errormessage=\"wpforms-1478-field_160-error\"><p>I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy).<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_161-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"161\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy). <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_161\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_161_1\" name=\"wpforms[fields][161]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_161_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_161_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_161_2\" name=\"wpforms[fields][161]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_161_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_161_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_83-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"83\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_84-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"84\"><div id=\"wpforms-1478-field_84\" aria-errormessage=\"wpforms-1478-field_84-error\"><span class=\"numero-preg\">3<\/span><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_85-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"85\"><div id=\"wpforms-1478-field_85\" aria-errormessage=\"wpforms-1478-field_85-error\"><p>I struggle to perform moderate exercise (for example, walk 1.6 kilometer\/one mile in 14 minutes or swim 200 meters\/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_86-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns\" data-field-id=\"86\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">I struggle to perform moderate exercise (for example, walk 1.6 kilometer\/one mile in 14 minutes or swim 200 meters\/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_86\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_86_1\" name=\"wpforms[fields][86]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_86_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_86_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_86_2\" name=\"wpforms[fields][86]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_86_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_86_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_87-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"87\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_88-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"88\"><div id=\"wpforms-1478-field_88\" aria-errormessage=\"wpforms-1478-field_88-error\"><span class=\"numero-preg\">4<\/span><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_89-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"89\"><div id=\"wpforms-1478-field_89\" aria-errormessage=\"wpforms-1478-field_89-error\"><p>I have had problems with my eyes, ears, or nasal passages\/sinuses.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_90-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-trigger\" data-field-id=\"90\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">I have had problems with my eyes, ears, or nasal passages\/sinuses. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_90\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_90_1\" name=\"wpforms[fields][90]\" value=\"Yes\" aria-errormessage=\"wpforms-1478-field_90_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_90_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_90_2\" name=\"wpforms[fields][90]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_90_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_90_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_162-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"162\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_163-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"163\" style=\"display:none;\"><div id=\"wpforms-1478-field_163\" aria-errormessage=\"wpforms-1478-field_163-error\"><p>Sinus surgery within the last 6 months.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_164-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"164\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Sinus surgery within the last 6 months. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_164\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_164_1\" name=\"wpforms[fields][164]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_164_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_164_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_164_2\" name=\"wpforms[fields][164]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_164_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_164_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_165-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"165\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_166-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"166\" style=\"display:none;\"><div id=\"wpforms-1478-field_166\" aria-errormessage=\"wpforms-1478-field_166-error\"><p>Ear disease or ear surgery, hearing loss, or problems with balance.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_167-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"167\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Ear disease or ear surgery, hearing loss, or problems with balance. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_167\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_167_1\" name=\"wpforms[fields][167]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_167_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_167_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_167_2\" name=\"wpforms[fields][167]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_167_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_167_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_168-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"168\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_169-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"169\" style=\"display:none;\"><div id=\"wpforms-1478-field_169\" aria-errormessage=\"wpforms-1478-field_169-error\"><p>Recurrent sinusitis within the past 12 months.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_170-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"170\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Recurrent sinusitis within the past 12 months. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_170\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_170_1\" name=\"wpforms[fields][170]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_170_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_170_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_170_2\" name=\"wpforms[fields][170]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_170_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_170_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_171-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"171\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_172-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"172\" style=\"display:none;\"><div id=\"wpforms-1478-field_172\" aria-errormessage=\"wpforms-1478-field_172-error\"><p>Eye surgery within the past 3 months.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_173-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"173\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Eye surgery within the past 3 months. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_173\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_173_1\" name=\"wpforms[fields][173]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_173_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_173_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_173_2\" name=\"wpforms[fields][173]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_173_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_173_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_91-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"91\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_92-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"92\"><div id=\"wpforms-1478-field_92\" aria-errormessage=\"wpforms-1478-field_92-error\"><span class=\"numero-preg\">5<\/span><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_93-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"93\"><div id=\"wpforms-1478-field_93\" aria-errormessage=\"wpforms-1478-field_93-error\"><p>I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_94-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns\" data-field-id=\"94\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_94\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_94_1\" name=\"wpforms[fields][94]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_94_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_94_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_94_2\" name=\"wpforms[fields][94]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_94_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_94_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_95-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"95\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_96-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"96\"><div id=\"wpforms-1478-field_96\" aria-errormessage=\"wpforms-1478-field_96-error\"><span class=\"numero-preg\">6<\/span><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_97-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"97\"><div id=\"wpforms-1478-field_97\" aria-errormessage=\"wpforms-1478-field_97-error\"><p>I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_98-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-trigger\" data-field-id=\"98\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_98\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_98_1\" name=\"wpforms[fields][98]\" value=\"Yes\" aria-errormessage=\"wpforms-1478-field_98_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_98_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_98_2\" name=\"wpforms[fields][98]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_98_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_98_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_174-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"174\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_175-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"175\" style=\"display:none;\"><div id=\"wpforms-1478-field_175\" aria-errormessage=\"wpforms-1478-field_175-error\"><p>Head injury with loss of consciousness within the past 5 years.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_176-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"176\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Head injury with loss of consciousness within the past 5 years. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_176\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_176_1\" name=\"wpforms[fields][176]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_176_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_176_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_176_2\" name=\"wpforms[fields][176]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_176_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_176_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_177-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"177\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_178-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"178\" style=\"display:none;\"><div id=\"wpforms-1478-field_178\" aria-errormessage=\"wpforms-1478-field_178-error\"><p>Persistent neurologic injury or disease.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_179-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"179\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Persistent neurologic injury or disease. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_179\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_179_1\" name=\"wpforms[fields][179]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_179_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_179_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_179_2\" name=\"wpforms[fields][179]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_179_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_179_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_180-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"180\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_181-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"181\" style=\"display:none;\"><div id=\"wpforms-1478-field_181\" aria-errormessage=\"wpforms-1478-field_181-error\"><p>Recurring migraine headaches within the past 12 months, or take medications to prevent them.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_182-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"182\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Recurring migraine headaches within the past 12 months, or take medications to prevent them. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_182\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_182_1\" name=\"wpforms[fields][182]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_182_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_182_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_182_2\" name=\"wpforms[fields][182]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_182_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_182_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_183-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"183\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_184-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"184\" style=\"display:none;\"><div id=\"wpforms-1478-field_184\" aria-errormessage=\"wpforms-1478-field_184-error\"><p>Blackouts or fainting (full\/partial loss of consciousness) within the last 5 years.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_185-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"185\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Blackouts or fainting (full\/partial loss of consciousness) within the last 5 years. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_185\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_185_1\" name=\"wpforms[fields][185]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_185_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_185_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_185_2\" name=\"wpforms[fields][185]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_185_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_185_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_186-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"186\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_187-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"187\" style=\"display:none;\"><div id=\"wpforms-1478-field_187\" aria-errormessage=\"wpforms-1478-field_187-error\"><p>Epilepsy, seizures, or convulsions, OR take medications to prevent them.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_188-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"188\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Epilepsy, seizures, or convulsions, OR take medications to prevent them. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_188\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_188_1\" name=\"wpforms[fields][188]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_188_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_188_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_188_2\" name=\"wpforms[fields][188]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_188_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_188_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_99-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"99\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_100-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"100\"><div id=\"wpforms-1478-field_100\" aria-errormessage=\"wpforms-1478-field_100-error\"><span class=\"numero-preg\">7<\/span><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_101-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"101\"><div id=\"wpforms-1478-field_101\" aria-errormessage=\"wpforms-1478-field_101-error\"><p>I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic\nattacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning or developmental disability.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_102-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-trigger\" data-field-id=\"102\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic\nattacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning or developmental disability. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_102\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_102_1\" name=\"wpforms[fields][102]\" value=\"Yes\" aria-errormessage=\"wpforms-1478-field_102_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_102_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_102_2\" name=\"wpforms[fields][102]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_102_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_102_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_189-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"189\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_190-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"190\" style=\"display:none;\"><div id=\"wpforms-1478-field_190\" aria-errormessage=\"wpforms-1478-field_190-error\"><p>Behavioral health, mental or psychological problems requiring medical\/psychiatric treatment.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_191-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"191\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Behavioral health, mental or psychological problems requiring medical\/psychiatric treatment. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_191\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_191_1\" name=\"wpforms[fields][191]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_191_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_191_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_191_2\" name=\"wpforms[fields][191]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_191_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_191_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_192-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"192\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_193-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"193\" style=\"display:none;\"><div id=\"wpforms-1478-field_193\" aria-errormessage=\"wpforms-1478-field_193-error\"><p>Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication\/psychiatric treatment.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_194-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"194\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication\/psychiatric treatment. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_194\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_194_1\" name=\"wpforms[fields][194]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_194_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_194_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_194_2\" name=\"wpforms[fields][194]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_194_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_194_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_195-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"195\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_196-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"196\" style=\"display:none;\"><div id=\"wpforms-1478-field_196\" aria-errormessage=\"wpforms-1478-field_196-error\"><p>Been diagnosed with a mental health condition or a learning\/developmental disorder that requires ongoing care or special accommodation.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_197-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"197\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Been diagnosed with a mental health condition or a learning\/developmental disorder that requires ongoing care or special accommodation. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_197\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_197_1\" name=\"wpforms[fields][197]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_197_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_197_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_197_2\" name=\"wpforms[fields][197]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_197_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_197_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_198-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"198\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_199-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"199\" style=\"display:none;\"><div id=\"wpforms-1478-field_199\" aria-errormessage=\"wpforms-1478-field_199-error\"><p>An addiction to drugs or alcohol requiring treatment within the last 5 years.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_200-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"200\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">An addiction to drugs or alcohol requiring treatment within the last 5 years. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_200\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_200_1\" name=\"wpforms[fields][200]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_200_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_200_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_200_2\" name=\"wpforms[fields][200]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_200_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_200_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_103-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"103\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_104-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"104\"><div id=\"wpforms-1478-field_104\" aria-errormessage=\"wpforms-1478-field_104-error\"><span class=\"numero-preg\">8<\/span><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_105-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"105\"><div id=\"wpforms-1478-field_105\" aria-errormessage=\"wpforms-1478-field_105-error\"><p>I have had back problems, hernia, ulcers, or diabetes.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_106-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-trigger\" data-field-id=\"106\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">I have had back problems, hernia, ulcers, or diabetes. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_106\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_106_1\" name=\"wpforms[fields][106]\" value=\"Yes\" aria-errormessage=\"wpforms-1478-field_106_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_106_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_106_2\" name=\"wpforms[fields][106]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_106_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_106_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_201-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"201\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_202-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"202\" style=\"display:none;\"><div id=\"wpforms-1478-field_202\" aria-errormessage=\"wpforms-1478-field_202-error\"><p>Recurrent back problems in the last 6 months that limit my everyday activity.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_203-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"203\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Recurrent back problems in the last 6 months that limit my everyday activity. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_203\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_203_1\" name=\"wpforms[fields][203]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_203_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_203_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_203_2\" name=\"wpforms[fields][203]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_203_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_203_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_205-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"205\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_206-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"206\" style=\"display:none;\"><div id=\"wpforms-1478-field_206\" aria-errormessage=\"wpforms-1478-field_206-error\"><p>Back or spinal surgery within the last 12 months.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_207-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"207\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Back or spinal surgery within the last 12 months. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_207\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_207_1\" name=\"wpforms[fields][207]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_207_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_207_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_207_2\" name=\"wpforms[fields][207]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_207_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_207_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_208-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"208\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_209-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"209\" style=\"display:none;\"><div id=\"wpforms-1478-field_209\" aria-errormessage=\"wpforms-1478-field_209-error\"><p>Diabetes, either drug or diet controlled, OR gestational diabetes within the last 12 months.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_210-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"210\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Diabetes, either drug or diet controlled, OR gestational diabetes within the last 12 months. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_210\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_210_1\" name=\"wpforms[fields][210]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_210_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_210_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_210_2\" name=\"wpforms[fields][210]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_210_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_210_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_211-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"211\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_212-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"212\" style=\"display:none;\"><div id=\"wpforms-1478-field_212\" aria-errormessage=\"wpforms-1478-field_212-error\"><p>An uncorrected hernia that limits my physical abilities.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_213-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"213\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">An uncorrected hernia that limits my physical abilities. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_213\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_213_1\" name=\"wpforms[fields][213]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_213_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_213_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_213_2\" name=\"wpforms[fields][213]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_213_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_213_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_214-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"214\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_215-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"215\" style=\"display:none;\"><div id=\"wpforms-1478-field_215\" aria-errormessage=\"wpforms-1478-field_215-error\"><p>Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_216-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"216\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_216\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_216_1\" name=\"wpforms[fields][216]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_216_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_216_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_216_2\" name=\"wpforms[fields][216]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_216_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_216_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_107-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"107\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_108-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"108\"><div id=\"wpforms-1478-field_108\" aria-errormessage=\"wpforms-1478-field_108-error\"><span class=\"numero-preg\">9<\/span><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_109-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"109\"><div id=\"wpforms-1478-field_109\" aria-errormessage=\"wpforms-1478-field_109-error\"><p>I have had stomach or intestine problems, including recent diarrhea.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_110-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-trigger\" data-field-id=\"110\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">I have had stomach or intestine problems, including recent diarrhea. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_110\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_110_1\" name=\"wpforms[fields][110]\" value=\"Yes\" aria-errormessage=\"wpforms-1478-field_110_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_110_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_110_2\" name=\"wpforms[fields][110]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_110_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_110_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_217-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"217\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_218-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"218\" style=\"display:none;\"><div id=\"wpforms-1478-field_218\" aria-errormessage=\"wpforms-1478-field_218-error\"><p>Ostomy surgery and do not have medical clearance to swim or engage in physical activity.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_219-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"219\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Ostomy surgery and do not have medical clearance to swim or engage in physical activity. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_219\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_219_1\" name=\"wpforms[fields][219]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_219_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_219_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_219_2\" name=\"wpforms[fields][219]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_219_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_219_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_220-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"220\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_221-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"221\" style=\"display:none;\"><div id=\"wpforms-1478-field_221\" aria-errormessage=\"wpforms-1478-field_221-error\"><p>Dehydration requiring medical intervention within the last 7 days.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_222-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"222\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Dehydration requiring medical intervention within the last 7 days. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_222\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_222_1\" name=\"wpforms[fields][222]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_222_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_222_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_222_2\" name=\"wpforms[fields][222]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_222_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_222_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_223-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"223\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_224-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"224\" style=\"display:none;\"><div id=\"wpforms-1478-field_224\" aria-errormessage=\"wpforms-1478-field_224-error\"><p>Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_225-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"225\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_225\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_225_1\" name=\"wpforms[fields][225]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_225_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_225_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_225_2\" name=\"wpforms[fields][225]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_225_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_225_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_226-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"226\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_227-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"227\" style=\"display:none;\"><div id=\"wpforms-1478-field_227\" aria-errormessage=\"wpforms-1478-field_227-error\"><p>Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_228-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"228\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD). <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_228\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_228_1\" name=\"wpforms[fields][228]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_228_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_228_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_228_2\" name=\"wpforms[fields][228]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_228_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_228_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_229-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"229\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_230-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"230\" style=\"display:none;\"><div id=\"wpforms-1478-field_230\" aria-errormessage=\"wpforms-1478-field_230-error\"><p>Active or uncontrolled ulcerative colitis or Crohn\u2019s disease.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_231-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"231\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Active or uncontrolled ulcerative colitis or Crohn\u2019s disease. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_231\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_231_1\" name=\"wpforms[fields][231]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_231_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_231_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_231_2\" name=\"wpforms[fields][231]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_231_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_231_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_232-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"232\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_233-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"233\" style=\"display:none;\"><div id=\"wpforms-1478-field_233\" aria-errormessage=\"wpforms-1478-field_233-error\"><p>Bariatric surgery within the last 12 months.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_234-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"234\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Bariatric surgery within the last 12 months. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_234\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_234_1\" name=\"wpforms[fields][234]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_234_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_234_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_234_2\" name=\"wpforms[fields][234]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_234_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_234_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_111-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"111\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-25-25-50\"><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_112-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"112\"><div id=\"wpforms-1478-field_112\" aria-errormessage=\"wpforms-1478-field_112-error\"><span class=\"numero-preg\">10<\/span><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1478-field_113-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"113\"><div id=\"wpforms-1478-field_113\" aria-errormessage=\"wpforms-1478-field_113-error\"><p>I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine (Lariam).<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_114-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-list-2-columns\" data-field-id=\"114\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine (Lariam). <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1478-field_114\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_114_1\" name=\"wpforms[fields][114]\" value=\"Yes *\" aria-errormessage=\"wpforms-1478-field_114_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_114_1\">Yes *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1478-field_114_2\" name=\"wpforms[fields][114]\" value=\"No\" aria-errormessage=\"wpforms-1478-field_114_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1478-field_114_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1478-field_116-container\" class=\"wpforms-field wpforms-field-html margin-top-bg\" data-field-id=\"116\"><div id=\"wpforms-1478-field_116\" aria-errormessage=\"wpforms-1478-field_116-error\"><h3>Participant Signature<\/h3>\n<p><b>If you answered NO to all 10 questions above, a medical evaluation is not required. Please read and agree to the participant statement below by signing and dating it.<\/b><\/p>\n<p><b>If you have answered \"Yes\" in any box marked with '*' it will be reviewed by the Diving Center staff and if we need additional information we will contact you.<\/b><\/p>\n<p><b>Participant Statement:  <\/b>I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting\nfrom any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.<\/p><\/div><\/div><div id=\"wpforms-1478-field_117-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"117\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1478-field_118-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"118\"><label class=\"wpforms-field-label\" for=\"wpforms-1478-field_118\">Participant&#039;s Signature <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1478-field_118\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][118]\" autocomplete=\"off\" inputmode=\"none\" aria-errormessage=\"wpforms-1478-field_118-error\" aria-describedby=\"wpforms-1478-field_118-description\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-1478-field_118-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Clear Signature\" tabindex=\"0\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"1em\" height=\"1em\" preserveAspectRatio=\"xMidYMid meet\" viewBox=\"0 0 1536 1536\">\n\t\t\t\t\t<path fill=\"var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )\" 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