{"id":1491,"date":"2024-04-18T10:54:18","date_gmt":"2024-04-18T09:54:18","guid":{"rendered":"https:\/\/divessl.com\/buceador-certificado\/"},"modified":"2024-04-19T13:23:43","modified_gmt":"2024-04-19T12:23:43","slug":"plongeur-certifie","status":"publish","type":"page","link":"https:\/\/divessl.com\/fr\/formulaire-dinscription\/plongeur-certifie\/","title":{"rendered":"Plongeur certifi\u00e9"},"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;]Formulaire d&#8217;inscription[\/vc_column_text]<style id=\"wpforms-css-vars-1480\">\n\t\t\t\t#wpforms-1480 {\n\t\t\t\t--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full ts-basic wpforms-render-modern\" id=\"wpforms-1480\"><form id=\"wpforms-form-1480\" class=\"wpforms-validate wpforms-form\" data-formid=\"1480\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/fr\/wp-json\/wp\/v2\/pages\/1491?wpforms_form_id=1480\" data-token=\"7ae94ab076adfdb35703e1549e37a09c\" data-token-time=\"1779333579\"><noscript class=\"wpforms-error-noscript\">Veuillez activer JavaScript dans votre navigateur pour remplir ce formulaire.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Veuillez activer JavaScript dans votre navigateur pour remplir ce formulaire.<\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \" data-page=\"1\"><div id=\"wpforms-1480-field_257-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"257\"><\/div><div id=\"wpforms-1480-field_250-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"250\"><div id=\"wpforms-1480-field_250\" aria-errormessage=\"wpforms-1480-field_250-error\"><h2>Plongeur certifi\u00e9<\/h2><\/div><\/div><div id=\"wpforms-1480-field_49-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"49\"><div id=\"wpforms-1480-field_49\" aria-errormessage=\"wpforms-1480-field_49-error\"><h3>Donn\u00e9es personnelles<\/h3><\/div><\/div><div id=\"wpforms-1480-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-1480-field_1-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_1\">Pr\u00e9nom <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1480-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" aria-errormessage=\"wpforms-1480-field_1-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-field_2-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_2\">Nom <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1480-field_2\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][2]\" aria-errormessage=\"wpforms-1480-field_2-error\" required><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_3\">Num\u00e9ro de passeport <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1480-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" aria-errormessage=\"wpforms-1480-field_3-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1480-field_4-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_4\">Date de naissance <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-1480-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-1480-field_4-error\" required><a title=\"Effacer la date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Effacer la date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1480-field_260-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"260\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_260\">Genre <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-1480-field_260\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][260]\" required=\"required\"><option value=\"Homme\"  class=\"choice-1 depth-1\"  >Homme<\/option><option value=\"Femme\"  class=\"choice-2 depth-1\"  >Femme<\/option><option value=\"Je ne veux pas dire\"  class=\"choice-3 depth-1\"  >Je ne veux pas dire<\/option><\/select><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_31\">Pays <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-1480-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=\"Albanie\"  class=\"choice-5 depth-1\"  >Albanie<\/option><option value=\"Allemagne\"  class=\"choice-6 depth-1\"  >Allemagne<\/option><option value=\"Andorre\"  class=\"choice-7 depth-1\"  >Andorre<\/option><option value=\"Angola\"  class=\"choice-8 depth-1\"  >Angola<\/option><option value=\"Anguilla\"  class=\"choice-9 depth-1\"  >Anguilla<\/option><option value=\"Antigua-et-Barbuda\"  class=\"choice-10 depth-1\"  >Antigua-et-Barbuda<\/option><option value=\"Antarctique\"  class=\"choice-11 depth-1\"  >Antarctique<\/option><option value=\"Alg\u00e9rie\"  class=\"choice-12 depth-1\"  >Alg\u00e9rie<\/option><option value=\"Argentine\"  class=\"choice-13 depth-1\"  >Argentine<\/option><option value=\"Arm\u00e9nie\"  class=\"choice-14 depth-1\"  >Arm\u00e9nie<\/option><option value=\"Aruba\"  class=\"choice-15 depth-1\"  >Aruba<\/option><option value=\"Australie\"  class=\"choice-16 depth-1\"  >Australie<\/option><option value=\"L&#039;Autriche\"  class=\"choice-17 depth-1\"  >L'Autriche<\/option><option value=\"Azerba\u00efdjan\"  class=\"choice-18 depth-1\"  >Azerba\u00efdjan<\/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=\"Bar\u00e9in\"  class=\"choice-22 depth-1\"  >Bar\u00e9in<\/option><option value=\"B\u00e9lize\"  class=\"choice-23 depth-1\"  >B\u00e9lize<\/option><option value=\"B\u00e9nin\"  class=\"choice-24 depth-1\"  >B\u00e9nin<\/option><option value=\"Bermudes\"  class=\"choice-25 depth-1\"  >Bermudes<\/option><option value=\"Bi\u00e9lorussie\"  class=\"choice-26 depth-1\"  >Bi\u00e9lorussie<\/option><option value=\"Bolivie, \u00c9tat plurinational de\"  class=\"choice-27 depth-1\"  >Bolivie, \u00c9tat plurinational de<\/option><option value=\"Bonaire, Saint-Eustache et Saba\"  class=\"choice-28 depth-1\"  >Bonaire, Saint-Eustache et Saba<\/option><option value=\"Bosnie Herz\u00e9govine\"  class=\"choice-29 depth-1\"  >Bosnie Herz\u00e9govine<\/option><option value=\"Botswana\"  class=\"choice-30 depth-1\"  >Botswana<\/option><option value=\"Br\u00e9sil\"  class=\"choice-31 depth-1\"  >Br\u00e9sil<\/option><option value=\"Brunei Darussalam\"  class=\"choice-32 depth-1\"  >Brunei Darussalam<\/option><option value=\"Bulgarie\"  class=\"choice-33 depth-1\"  >Bulgarie<\/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=\"Bhoutan\"  class=\"choice-36 depth-1\"  >Bhoutan<\/option><option value=\"Belgique\"  class=\"choice-37 depth-1\"  >Belgique<\/option><option value=\"Cap-Vert\"  class=\"choice-38 depth-1\"  >Cap-Vert<\/option><option value=\"Cambodge\"  class=\"choice-39 depth-1\"  >Cambodge<\/option><option value=\"Cameroun\"  class=\"choice-40 depth-1\"  >Cameroun<\/option><option value=\"Canada\"  class=\"choice-41 depth-1\"  >Canada<\/option><option value=\"Tchad\"  class=\"choice-42 depth-1\"  >Tchad<\/option><option value=\"Xil\u00e9\"  class=\"choice-43 depth-1\"  >Xil\u00e9<\/option><option value=\"Chine\"  class=\"choice-44 depth-1\"  >Chine<\/option><option value=\"Chypre\"  class=\"choice-45 depth-1\"  >Chypre<\/option><option value=\"Colombie\"  class=\"choice-46 depth-1\"  >Colombie<\/option><option value=\"Comores\"  class=\"choice-47 depth-1\"  >Comores<\/option><option value=\"Congo\"  class=\"choice-48 depth-1\"  >Congo<\/option><option value=\"Congo (R\u00e9publique d\u00e9mocratique du)\"  class=\"choice-49 depth-1\"  >Congo (R\u00e9publique d\u00e9mocratique du)<\/option><option value=\"Cor\u00e9e, R\u00e9publique de)\"  class=\"choice-50 depth-1\"  >Cor\u00e9e, R\u00e9publique de)<\/option><option value=\"Cor\u00e9e du Nord\"  class=\"choice-51 depth-1\"  >Cor\u00e9e du Nord<\/option><option value=\"Costa Rica\"  class=\"choice-52 depth-1\"  >Costa Rica<\/option><option value=\"C\u00f4te d&#039;Ivoire\"  class=\"choice-53 depth-1\"  >C\u00f4te d'Ivoire<\/option><option value=\"Croatie\"  class=\"choice-54 depth-1\"  >Croatie<\/option><option value=\"Cuba\"  class=\"choice-55 depth-1\"  >Cuba<\/option><option value=\"Curacao\"  class=\"choice-56 depth-1\"  >Curacao<\/option><option value=\"Danemark\"  class=\"choice-57 depth-1\"  >Danemark<\/option><option value=\"Dominique\"  class=\"choice-58 depth-1\"  >Dominique<\/option><option value=\"\u00c9quateur\"  class=\"choice-59 depth-1\"  >\u00c9quateur<\/option><option value=\"Egypte\"  class=\"choice-60 depth-1\"  >Egypte<\/option><option value=\"Le Salvador\"  class=\"choice-61 depth-1\"  >Le Salvador<\/option><option value=\"Emirats Arabes Unis\"  class=\"choice-62 depth-1\"  >Emirats Arabes Unis<\/option><option value=\"\u00c9rythr\u00e9e\"  class=\"choice-63 depth-1\"  >\u00c9rythr\u00e9e<\/option><option value=\"Slovaquie\"  class=\"choice-64 depth-1\"  >Slovaquie<\/option><option value=\"Slov\u00e9nie\"  class=\"choice-65 depth-1\"  >Slov\u00e9nie<\/option><option value=\"Espagne\"  selected='selected' class=\"choice-66 depth-1\"  >Espagne<\/option><option value=\"Saint-Si\u00e8ge (\u00c9tat de la Cit\u00e9 du Vatican)\"  class=\"choice-67 depth-1\"  >Saint-Si\u00e8ge (\u00c9tat de la Cit\u00e9 du Vatican)<\/option><option value=\"les \u00e9tats-unis d&#039;Am\u00e9rique\"  class=\"choice-68 depth-1\"  >les \u00e9tats-unis d'Am\u00e9rique<\/option><option value=\"Estonie\"  class=\"choice-69 depth-1\"  >Estonie<\/option><option value=\"Ethiopie\"  class=\"choice-70 depth-1\"  >Ethiopie<\/option><option value=\"F\u00e9d\u00e9ration Russe\"  class=\"choice-71 depth-1\"  >F\u00e9d\u00e9ration Russe<\/option><option value=\"Fidji\"  class=\"choice-72 depth-1\"  >Fidji<\/option><option value=\"Philippines\"  class=\"choice-73 depth-1\"  >Philippines<\/option><option value=\"Finlande\"  class=\"choice-74 depth-1\"  >Finlande<\/option><option value=\"France\"  class=\"choice-75 depth-1\"  >France<\/option><option value=\"Gabon\"  class=\"choice-76 depth-1\"  >Gabon<\/option><option value=\"Gambie\"  class=\"choice-77 depth-1\"  >Gambie<\/option><option value=\"G\u00e9orgie\"  class=\"choice-78 depth-1\"  >G\u00e9orgie<\/option><option value=\"Ghana\"  class=\"choice-79 depth-1\"  >Ghana<\/option><option value=\"Gibraltar\"  class=\"choice-80 depth-1\"  >Gibraltar<\/option><option value=\"Grenade\"  class=\"choice-81 depth-1\"  >Grenade<\/option><option value=\"Gr\u00e8ce\"  class=\"choice-82 depth-1\"  >Gr\u00e8ce<\/option><option value=\"Groenland\"  class=\"choice-83 depth-1\"  >Groenland<\/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=\"Guyane Fran\u00e7aise\"  class=\"choice-87 depth-1\"  >Guyane Fran\u00e7aise<\/option><option value=\"Guernesey\"  class=\"choice-88 depth-1\"  >Guernesey<\/option><option value=\"Guin\u00e9e\"  class=\"choice-89 depth-1\"  >Guin\u00e9e<\/option><option value=\"Guin\u00e9e \u00c9quatoriale\"  class=\"choice-90 depth-1\"  >Guin\u00e9e \u00c9quatoriale<\/option><option value=\"Guin\u00e9e-Bissau\"  class=\"choice-91 depth-1\"  >Guin\u00e9e-Bissau<\/option><option value=\"Guyane\"  class=\"choice-92 depth-1\"  >Guyane<\/option><option value=\"Ha\u00efti\"  class=\"choice-93 depth-1\"  >Ha\u00efti<\/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=\"Hongrie\"  class=\"choice-96 depth-1\"  >Hongrie<\/option><option value=\"Inde\"  class=\"choice-97 depth-1\"  >Inde<\/option><option value=\"Indon\u00e9sie\"  class=\"choice-98 depth-1\"  >Indon\u00e9sie<\/option><option value=\"Irak\"  class=\"choice-99 depth-1\"  >Irak<\/option><option value=\"Irlande (R\u00e9publique d&#039;)\"  class=\"choice-100 depth-1\"  >Irlande (R\u00e9publique d')<\/option><option value=\"R\u00e9publique islamique d&#039;Iran\"  class=\"choice-101 depth-1\"  >R\u00e9publique islamique d'Iran<\/option><option value=\"\u00cele Bouvet\"  class=\"choice-102 depth-1\"  >\u00cele Bouvet<\/option><option value=\"\u00eele de Man\"  class=\"choice-103 depth-1\"  >\u00eele de Man<\/option><option value=\"\u00eele de Man\"  class=\"choice-104 depth-1\"  >\u00eele de Man<\/option><option value=\"L&#039;\u00eele de no\u00ebl\"  class=\"choice-105 depth-1\"  >L'\u00eele de no\u00ebl<\/option><option value=\"Islande\"  class=\"choice-106 depth-1\"  >Islande<\/option><option value=\"\u00celes Cocos\"  class=\"choice-107 depth-1\"  >\u00celes Cocos<\/option><option value=\"\u00celes Cocos\"  class=\"choice-108 depth-1\"  >\u00celes Cocos<\/option><option value=\"les \u00celes Cook\"  class=\"choice-109 depth-1\"  >les \u00celes Cook<\/option><option value=\"\u00celes F\u00e9ro\u00e9\"  class=\"choice-110 depth-1\"  >\u00celes F\u00e9ro\u00e9<\/option><option value=\"\u00celes Heard et McDonald\"  class=\"choice-111 depth-1\"  >\u00celes Heard et McDonald<\/option><option value=\"\u00celes Falkland (Malvinas)\"  class=\"choice-112 depth-1\"  >\u00celes Falkland (Malvinas)<\/option><option value=\"\u00celes Mariannes du Nord\"  class=\"choice-113 depth-1\"  >\u00celes Mariannes du Nord<\/option><option value=\"Iles Marshall\"  class=\"choice-114 depth-1\"  >Iles Marshall<\/option><option value=\"Les \u00eeles Salomon\"  class=\"choice-115 depth-1\"  >Les \u00eeles Salomon<\/option><option value=\"\u00eeles Turques-et-Ca\u00efques\"  class=\"choice-116 depth-1\"  >\u00eeles Turques-et-Ca\u00efques<\/option><option value=\"\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis\"  class=\"choice-117 depth-1\"  >\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis<\/option><option value=\"\u00celes Vierges am\u00e9ricaines\"  class=\"choice-118 depth-1\"  >\u00celes Vierges am\u00e9ricaines<\/option><option value=\"\u00celes Vierges britanniques\"  class=\"choice-119 depth-1\"  >\u00celes Vierges britanniques<\/option><option value=\"G\u00e9orgie du Sud et \u00eeles Sandwich du Sud\"  class=\"choice-120 depth-1\"  >G\u00e9orgie du Sud et \u00eeles Sandwich du Sud<\/option><option value=\"Iles Aland\"  class=\"choice-121 depth-1\"  >Iles Aland<\/option><option value=\"Isra\u00ebl\"  class=\"choice-122 depth-1\"  >Isra\u00ebl<\/option><option value=\"Italie\"  class=\"choice-123 depth-1\"  >Italie<\/option><option value=\"Jama\u00efque\"  class=\"choice-124 depth-1\"  >Jama\u00efque<\/option><option value=\"Japon\"  class=\"choice-125 depth-1\"  >Japon<\/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=\"Kirghizistan\"  class=\"choice-131 depth-1\"  >Kirghizistan<\/option><option value=\"Kiribati\"  class=\"choice-132 depth-1\"  >Kiribati<\/option><option value=\"Kosovo\"  class=\"choice-133 depth-1\"  >Kosovo<\/option><option value=\"Kowe\u00eft\"  class=\"choice-134 depth-1\"  >Kowe\u00eft<\/option><option value=\"Lesotho\"  class=\"choice-135 depth-1\"  >Lesotho<\/option><option value=\"Lettonie\"  class=\"choice-136 depth-1\"  >Lettonie<\/option><option value=\"Lib\u00e9ria\"  class=\"choice-137 depth-1\"  >Lib\u00e9ria<\/option><option value=\"Libye\"  class=\"choice-138 depth-1\"  >Libye<\/option><option value=\"Liechtenstein\"  class=\"choice-139 depth-1\"  >Liechtenstein<\/option><option value=\"Lituanie\"  class=\"choice-140 depth-1\"  >Lituanie<\/option><option value=\"Luxembourg\"  class=\"choice-141 depth-1\"  >Luxembourg<\/option><option value=\"Liban\"  class=\"choice-142 depth-1\"  >Liban<\/option><option value=\"Macao\"  class=\"choice-143 depth-1\"  >Macao<\/option><option value=\"Mac\u00e9doine du Nord (R\u00e9publique de)\"  class=\"choice-144 depth-1\"  >Mac\u00e9doine du Nord (R\u00e9publique de)<\/option><option value=\" Madagascar\"  class=\"choice-145 depth-1\"  >Madagascar<\/option><option value=\"Malaisie\"  class=\"choice-146 depth-1\"  >Malaisie<\/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=\"Malte\"  class=\"choice-150 depth-1\"  >Malte<\/option><option value=\"Maroc\"  class=\"choice-151 depth-1\"  >Maroc<\/option><option value=\"Martinique\"  class=\"choice-152 depth-1\"  >Martinique<\/option><option value=\"Maurice\"  class=\"choice-153 depth-1\"  >Maurice<\/option><option value=\"Mauritanie\"  class=\"choice-154 depth-1\"  >Mauritanie<\/option><option value=\"Mayotte\"  class=\"choice-155 depth-1\"  >Mayotte<\/option><option value=\"Micron\u00e9sie, \u00c9tats f\u00e9d\u00e9r\u00e9s de\"  class=\"choice-156 depth-1\"  >Micron\u00e9sie, \u00c9tats f\u00e9d\u00e9r\u00e9s de<\/option><option value=\"Moldavie\"  class=\"choice-157 depth-1\"  >Moldavie<\/option><option value=\"Mongolie\"  class=\"choice-158 depth-1\"  >Mongolie<\/option><option value=\"Mont\u00e9n\u00e9gro\"  class=\"choice-159 depth-1\"  >Mont\u00e9n\u00e9gro<\/option><option value=\"Montserrat\"  class=\"choice-160 depth-1\"  >Montserrat<\/option><option value=\"Mozambique\"  class=\"choice-161 depth-1\"  >Mozambique<\/option><option value=\"Birmanie\"  class=\"choice-162 depth-1\"  >Birmanie<\/option><option value=\"Mexique\"  class=\"choice-163 depth-1\"  >Mexique<\/option><option value=\"Monaco\"  class=\"choice-164 depth-1\"  >Monaco<\/option><option value=\"Namibie\"  class=\"choice-165 depth-1\"  >Namibie<\/option><option value=\"Nauru\"  class=\"choice-166 depth-1\"  >Nauru<\/option><option value=\"N\u00e9pal\"  class=\"choice-167 depth-1\"  >N\u00e9pal<\/option><option value=\"Nicaragua\"  class=\"choice-168 depth-1\"  >Nicaragua<\/option><option value=\"Nigeria\"  class=\"choice-169 depth-1\"  >Nigeria<\/option><option value=\"Niou\u00e9\"  class=\"choice-170 depth-1\"  >Niou\u00e9<\/option><option value=\"Norv\u00e8ge\"  class=\"choice-171 depth-1\"  >Norv\u00e8ge<\/option><option value=\"Nouvelle Cal\u00e9donie\"  class=\"choice-172 depth-1\"  >Nouvelle Cal\u00e9donie<\/option><option value=\"Nouvelle-Z\u00e9lande\"  class=\"choice-173 depth-1\"  >Nouvelle-Z\u00e9lande<\/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=\"Palaos\"  class=\"choice-177 depth-1\"  >Palaos<\/option><option value=\"Palestine (\u00c9tat de)\"  class=\"choice-178 depth-1\"  >Palestine (\u00c9tat de)<\/option><option value=\"Panama\"  class=\"choice-179 depth-1\"  >Panama<\/option><option value=\"Papouasie Nouvelle Guin\u00e9e\"  class=\"choice-180 depth-1\"  >Papouasie Nouvelle Guin\u00e9e<\/option><option value=\"Paraguay\"  class=\"choice-181 depth-1\"  >Paraguay<\/option><option value=\"Pays-Bas\"  class=\"choice-182 depth-1\"  >Pays-Bas<\/option><option value=\"P\u00e9rou\"  class=\"choice-183 depth-1\"  >P\u00e9rou<\/option><option value=\"Pitcairn\"  class=\"choice-184 depth-1\"  >Pitcairn<\/option><option value=\"Polyn\u00e9sie fran\u00e7aise\"  class=\"choice-185 depth-1\"  >Polyn\u00e9sie fran\u00e7aise<\/option><option value=\"Pologne\"  class=\"choice-186 depth-1\"  >Pologne<\/option><option value=\"Portugal\"  class=\"choice-187 depth-1\"  >Portugal<\/option><option value=\"Porto Rico\"  class=\"choice-188 depth-1\"  >Porto Rico<\/option><option value=\"Royaume-Uni de Grande-Bretagne et d&#039;Irlande du Nord\"  class=\"choice-189 depth-1\"  >Royaume-Uni de Grande-Bretagne et d'Irlande du Nord<\/option><option value=\"R\u00e9publique centrafricaine\"  class=\"choice-190 depth-1\"  >R\u00e9publique centrafricaine<\/option><option value=\"R\u00e9publique tch\u00e8que\"  class=\"choice-191 depth-1\"  >R\u00e9publique tch\u00e8que<\/option><option value=\"R\u00e9publique dominicaine\"  class=\"choice-192 depth-1\"  >R\u00e9publique dominicaine<\/option><option value=\"R\u00e9publique d\u00e9mocratique populaire lao\"  class=\"choice-193 depth-1\"  >R\u00e9publique d\u00e9mocratique populaire lao<\/option><option value=\"R\u00e9publique arabe syrienne\"  class=\"choice-194 depth-1\"  >R\u00e9publique arabe syrienne<\/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=\"Roumanie\"  class=\"choice-197 depth-1\"  >Roumanie<\/option><option value=\"Saint-Christophe-et-Ni\u00e9v\u00e8s\"  class=\"choice-198 depth-1\"  >Saint-Christophe-et-Ni\u00e9v\u00e8s<\/option><option value=\"Samoa\"  class=\"choice-199 depth-1\"  >Samoa<\/option><option value=\"Samoa am\u00e9ricaines\"  class=\"choice-200 depth-1\"  >Samoa am\u00e9ricaines<\/option><option value=\"Saint Barth\u00e9lemy\"  class=\"choice-201 depth-1\"  >Saint Barth\u00e9lemy<\/option><option value=\"Saint Marin\"  class=\"choice-202 depth-1\"  >Saint Marin<\/option><option value=\"Saint-Martin (partie fran\u00e7aise)\"  class=\"choice-203 depth-1\"  >Saint-Martin (partie fran\u00e7aise)<\/option><option value=\"Saint-Martin (partie n\u00e9erlandaise)\"  class=\"choice-204 depth-1\"  >Saint-Martin (partie n\u00e9erlandaise)<\/option><option value=\"Saint-Pierre-et-Miquelon\"  class=\"choice-205 depth-1\"  >Saint-Pierre-et-Miquelon<\/option><option value=\"Saint-Vincent-et-les Grenadines\"  class=\"choice-206 depth-1\"  >Saint-Vincent-et-les Grenadines<\/option><option value=\"Sainte-H\u00e9l\u00e8ne, Ascension et Tristan da Cunha\"  class=\"choice-207 depth-1\"  >Sainte-H\u00e9l\u00e8ne, Ascension et Tristan da Cunha<\/option><option value=\"Santa Lucia\"  class=\"choice-208 depth-1\"  >Santa Lucia<\/option><option value=\"Sao Tom\u00e9 et Principe\"  class=\"choice-209 depth-1\"  >Sao Tom\u00e9 et Principe<\/option><option value=\"Arabie Saoudite\"  class=\"choice-210 depth-1\"  >Arabie Saoudite<\/option><option value=\"S\u00e9n\u00e9gal\"  class=\"choice-211 depth-1\"  >S\u00e9n\u00e9gal<\/option><option value=\"Serbie\"  class=\"choice-212 depth-1\"  >Serbie<\/option><option value=\"les Seychelles\"  class=\"choice-213 depth-1\"  >les Seychelles<\/option><option value=\"Sierra Leone\"  class=\"choice-214 depth-1\"  >Sierra Leone<\/option><option value=\"Singapour\"  class=\"choice-215 depth-1\"  >Singapour<\/option><option value=\"Somalie\"  class=\"choice-216 depth-1\"  >Somalie<\/option><option value=\"Sri Lanka\"  class=\"choice-217 depth-1\"  >Sri Lanka<\/option><option value=\"Swaziland (Royaume du)\"  class=\"choice-218 depth-1\"  >Swaziland (Royaume du)<\/option><option value=\"Afrique du Sud\"  class=\"choice-219 depth-1\"  >Afrique du Sud<\/option><option value=\"Soudan\"  class=\"choice-220 depth-1\"  >Soudan<\/option><option value=\"Soudan du sud\"  class=\"choice-221 depth-1\"  >Soudan du sud<\/option><option value=\"Su\u00e8de\"  class=\"choice-222 depth-1\"  >Su\u00e8de<\/option><option value=\"Suisse\"  class=\"choice-223 depth-1\"  >Suisse<\/option><option value=\"Suriname\"  class=\"choice-224 depth-1\"  >Suriname<\/option><option value=\"Svalbard et Jan Mayen\"  class=\"choice-225 depth-1\"  >Svalbard et Jan Mayen<\/option><option value=\"Sahara occidental\"  class=\"choice-226 depth-1\"  >Sahara occidental<\/option><option value=\"Tha\u00eflande\"  class=\"choice-227 depth-1\"  >Tha\u00eflande<\/option><option value=\"Ta\u00efwan, R\u00e9publique de Chine\"  class=\"choice-228 depth-1\"  >Ta\u00efwan, R\u00e9publique de Chine<\/option><option value=\"Tanzanie (R\u00e9publique-Unie de)\"  class=\"choice-229 depth-1\"  >Tanzanie (R\u00e9publique-Unie de)<\/option><option value=\"Tadjikistan\"  class=\"choice-230 depth-1\"  >Tadjikistan<\/option><option value=\"Territoire britannique de l&#039;oc\u00e9an Indien\"  class=\"choice-231 depth-1\"  >Territoire britannique de l'oc\u00e9an Indien<\/option><option value=\"Terres australes et antarctiques fran\u00e7aises\"  class=\"choice-232 depth-1\"  >Terres australes et antarctiques fran\u00e7aises<\/option><option value=\"Timor-Leste\"  class=\"choice-233 depth-1\"  >Timor-Leste<\/option><option value=\"Aller\"  class=\"choice-234 depth-1\"  >Aller<\/option><option value=\"Tok\u00e9laou\"  class=\"choice-235 depth-1\"  >Tok\u00e9laou<\/option><option value=\"Tonga\"  class=\"choice-236 depth-1\"  >Tonga<\/option><option value=\"Trinit\u00e9 et Tobago\"  class=\"choice-237 depth-1\"  >Trinit\u00e9 et Tobago<\/option><option value=\"Turkm\u00e9nistan\"  class=\"choice-238 depth-1\"  >Turkm\u00e9nistan<\/option><option value=\"Tuvalu\"  class=\"choice-239 depth-1\"  >Tuvalu<\/option><option value=\"Tunisie\"  class=\"choice-240 depth-1\"  >Tunisie<\/option><option value=\"Turquie\"  class=\"choice-241 depth-1\"  >Turquie<\/option><option value=\"Ukraine\"  class=\"choice-242 depth-1\"  >Ukraine<\/option><option value=\"Ouganda\"  class=\"choice-243 depth-1\"  >Ouganda<\/option><option value=\"Uruguay\"  class=\"choice-244 depth-1\"  >Uruguay<\/option><option value=\"Ouzb\u00e9kistan\"  class=\"choice-245 depth-1\"  >Ouzb\u00e9kistan<\/option><option value=\"Vanuatu\"  class=\"choice-246 depth-1\"  >Vanuatu<\/option><option value=\"Venezuela (R\u00e9publique bolivarienne du)\"  class=\"choice-247 depth-1\"  >Venezuela (R\u00e9publique bolivarienne du)<\/option><option value=\"Vi\u00eat Nam\"  class=\"choice-248 depth-1\"  >Vi\u00eat Nam<\/option><option value=\"Wallis et Futuna\"  class=\"choice-249 depth-1\"  >Wallis et Futuna<\/option><option value=\"Y\u00e9men\"  class=\"choice-250 depth-1\"  >Y\u00e9men<\/option><option value=\"Djibouti\"  class=\"choice-251 depth-1\"  >Djibouti<\/option><option value=\"Zambie\"  class=\"choice-252 depth-1\"  >Zambie<\/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-1480-field_5-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_5\">Code postal <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1480-field_5\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][5]\" aria-errormessage=\"wpforms-1480-field_5-error\" required><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-field_33-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_33\">Tel\u00e9phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-1480-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=\"Tel\u00e9phone\" aria-errormessage=\"wpforms-1480-field_33-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-field_6-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_6\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-1480-field_6\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][6]\" spellcheck=\"false\" aria-errormessage=\"wpforms-1480-field_6-error\" required><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-field_255-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"255\"><div id=\"wpforms-1480-field_255\" aria-errormessage=\"wpforms-1480-field_255-error\"><p><b>Voulez-vous que nous vous taguions sur vos photos\/vid\u00e9os sur les r\u00e9seaux sociaux\u00a0?<\/b><\/p><\/div><\/div><div id=\"wpforms-1480-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-1480-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_8\">Instagram<\/label><input type=\"text\" id=\"wpforms-1480-field_8\" class=\"wpforms-field-medium\" name=\"wpforms[fields][8]\" placeholder=\"@\" aria-errormessage=\"wpforms-1480-field_8-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_9\">TikTok<\/label><input type=\"text\" id=\"wpforms-1480-field_9\" class=\"wpforms-field-medium\" name=\"wpforms[fields][9]\" placeholder=\"@\" aria-errormessage=\"wpforms-1480-field_9-error\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-field_50-container\" class=\"wpforms-field wpforms-field-html txt-red margin-top-bg\" data-field-id=\"50\"><div id=\"wpforms-1480-field_50\" aria-errormessage=\"wpforms-1480-field_50-error\"><h3>Si vous \u00eates mineur, les donn\u00e9es doivent \u00eatre remplies par le p\u00e8re\/la m\u00e8re\/le tuteur l\u00e9gal:<\/h3><\/div><\/div><div id=\"wpforms-1480-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-1480-field_10-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-trigger\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_10\">Pr\u00e9nom<\/label><input type=\"text\" id=\"wpforms-1480-field_10\" class=\"wpforms-field-medium\" name=\"wpforms[fields][10]\" aria-errormessage=\"wpforms-1480-field_10-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_11\">Nom<\/label><input type=\"text\" id=\"wpforms-1480-field_11\" class=\"wpforms-field-medium\" name=\"wpforms[fields][11]\" aria-errormessage=\"wpforms-1480-field_11-error\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_12\">Num\u00e9ro de passeport<\/label><input type=\"text\" id=\"wpforms-1480-field_12\" class=\"wpforms-field-medium\" name=\"wpforms[fields][12]\" aria-errormessage=\"wpforms-1480-field_12-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-field_37-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"37\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_37\">Tel\u00e9phone<\/label><input type=\"tel\" id=\"wpforms-1480-field_37\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][37]\" aria-label=\"Tel\u00e9phone\" aria-errormessage=\"wpforms-1480-field_37-error\" ><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-field_51-container\" class=\"wpforms-field wpforms-field-html margin-top-bg\" data-field-id=\"51\"><div id=\"wpforms-1480-field_51\" aria-errormessage=\"wpforms-1480-field_51-error\"><h3>Informations pour l\u2019activit\u00e9\n<\/h3><\/div><\/div><div id=\"wpforms-1480-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-1480-field_13-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_13\">Date d\u2019arriv\u00e9e <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-1480-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-1480-field_13-error\" required><a title=\"Effacer la date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Effacer la date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-field_14-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_14\">Date de d\u00e9part <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-1480-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=\"0\" data-input=\"true\" name=\"wpforms[fields][14][date]\" aria-errormessage=\"wpforms-1480-field_14-error\" required><a title=\"Effacer la date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Effacer la date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-field_15-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_15\">H\u00e9bergement <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1480-field_15\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][15]\" aria-errormessage=\"wpforms-1480-field_15-error\" required><\/div><div id=\"wpforms-1480-field_239-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"239\"><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-1480-field_240-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"240\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_240\">Certification <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1480-field_240\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][240]\" aria-errormessage=\"wpforms-1480-field_240-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-1480-field_244-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"244\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_244\">Nombre de plong\u00e9es <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-1480-field_244\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][244]\" step=\"any\" aria-errormessage=\"wpforms-1480-field_244-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-1480-field_243-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"243\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_243\">Dernier rendez-vous <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-1480-field_243\" 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][243][date]\" aria-errormessage=\"wpforms-1480-field_243-error\" required><a title=\"Effacer la date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Effacer la date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-field_245-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"245\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-field_248-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-conditional-trigger\" data-field-id=\"248\"><fieldset><legend class=\"wpforms-field-label\">Assurance de plong\u00e9e <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_248\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_248_1\" name=\"wpforms[fields][248]\" value=\"Oui\" aria-errormessage=\"wpforms-1480-field_248_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_248_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_248_2\" name=\"wpforms[fields][248]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_248_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_248_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-field_247-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"247\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_247\">Date d&#039;expiration <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-1480-field_247\" 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][247][date]\" aria-errormessage=\"wpforms-1480-field_247-error\" required><a title=\"Effacer la date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Effacer la date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-field_259-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"259\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_259\">Certificat de plong\u00e9e <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div\n\t\tclass=\"wpforms-uploader wpforms-field-required\"\n\t\tdata-field-id=\"259\"\n\t\tdata-form-id=\"1480\"\n\t\tdata-input-name=\"wpforms_1480_259\"\n\t\tdata-extensions=\"pdf,png,jpg\"\n\t\tdata-max-size=\"4194304\"\n\t\tdata-max-file-number=\"2\"\n\t\tdata-post-max-size=\"31457280\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg  viewBox=\"0 0 640 640\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M352 173.3L352 384C352 401.7 337.7 416 320 416C302.3 416 288 401.7 288 384L288 173.3L246.6 214.7C234.1 227.2 213.8 227.2 201.3 214.7C188.8 202.2 188.8 181.9 201.3 169.4L297.3 73.4C309.8 60.9 330.1 60.9 342.6 73.4L438.6 169.4C451.1 181.9 451.1 202.2 438.6 214.7C426.1 227.2 405.8 227.2 393.3 214.7L352 173.3zM320 464C364.2 464 400 428.2 400 384L480 384C515.3 384 544 412.7 544 448L544 480C544 515.3 515.3 544 480 544L160 544C124.7 544 96 515.3 96 480L96 448C96 412.7 124.7 384 160 384L240 384C240 428.2 275.8 464 320 464zM464 488C477.3 488 488 477.3 488 464C488 450.7 477.3 440 464 440C450.7 440 440 450.7 440 464C440 477.3 450.7 488 464 488z\"\/>\n\t\t<\/svg>\n\n\t\t<span class=\"modern-title\">\n\t\t\t\t\t\t\tDrag &amp; Drop Files, \t\t\t\t<span>Choose Files to Upload<\/span>\n\t\t\t\t\t<\/span>\n\n\t\t\t\t\t<span class=\"modern-hint\">Vous pouvez t\u00e9l\u00e9verser jusqu\u2019\u00e0 2 fichiers.<\/span>\n\t\t\t<\/div>\n<\/div>\n\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-1480-field_259\"\n\t\tname=\"wpforms_1480_259\" required\t\tvalue=\"\">\n<div id=\"wpforms-1480-field_259-description\" class=\"wpforms-field-description\">Joignez votre certificat de plong\u00e9e et v\u00e9rifiez que votre nom complet et votre niveau de plong\u00e9e figurent sur le document (les formats accept\u00e9s sont :  .pdf, .png, .jpg; max. 4Mb)<\/div><\/div><div id=\"wpforms-1480-field_52-container\" class=\"wpforms-field wpforms-field-html margin-top-bg\" data-field-id=\"52\"><div id=\"wpforms-1480-field_52\" aria-errormessage=\"wpforms-1480-field_52-error\"><p>A contacter en cas d\u2019urgence:<\/p><\/div><\/div><div id=\"wpforms-1480-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-1480-field_16-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_16\">Pr\u00e9nom <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1480-field_16\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][16]\" aria-errormessage=\"wpforms-1480-field_16-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-1480-field_17-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_17\">Nom <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1480-field_17\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][17]\" aria-errormessage=\"wpforms-1480-field_17-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-1480-field_40-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"40\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_40\">Tel\u00e9phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-1480-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=\"Tel\u00e9phone\" aria-errormessage=\"wpforms-1480-field_40-error\" required><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-field_249-container\" class=\"wpforms-field wpforms-field-radio si-no wpforms-conditional-trigger\" data-field-id=\"249\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous besoin de location de mat\u00e9riel? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_249\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_249_1\" name=\"wpforms[fields][249]\" value=\"Oui\" aria-errormessage=\"wpforms-1480-field_249_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_249_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_249_2\" name=\"wpforms[fields][249]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_249_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_249_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1480-field_251-container\" class=\"wpforms-field wpforms-field-html margin-top-bg wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"251\" style=\"display:none;\"><div id=\"wpforms-1480-field_251\" aria-errormessage=\"wpforms-1480-field_251-error\"><p>Informations n\u00e9cessaires pour pr\u00e9parer votre mat\u00e9riel de plong\u00e9e\u00a0:<\/p><\/div><\/div><div id=\"wpforms-1480-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-1480-field_18-container\" class=\"wpforms-field wpforms-field-number wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"18\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_18\">Taille (cm) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-1480-field_18\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][18]\" step=\"any\" aria-errormessage=\"wpforms-1480-field_18-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-1480-field_19-container\" class=\"wpforms-field wpforms-field-number wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"19\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_19\">Poids (kg) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-1480-field_19\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][19]\" step=\"any\" aria-errormessage=\"wpforms-1480-field_19-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\" ><div id=\"wpforms-1480-field_20-container\" class=\"wpforms-field wpforms-field-number wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"20\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_20\">Pointure (EU) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-1480-field_20\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][20]\" step=\"any\" aria-errormessage=\"wpforms-1480-field_20-error\" required><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-field_57-container\" class=\"wpforms-field wpforms-field-html margin-top-bg\" data-field-id=\"57\"><div id=\"wpforms-1480-field_57\" aria-errormessage=\"wpforms-1480-field_57-error\"><h3>Je d\u00e9clare que:<\/h3>\n<ol>\n<li><p>Je suis conscient de la r\u00e9glementation en vigueur et m'engage \u00e0 effectuer les plong\u00e9es selon ces r\u00e8gles et dans les limites de ma formation. La loi espagnole exige une assurance plong\u00e9e, \u00e0 pr\u00e9senter au personnel de l'\u00e9cole si n\u00e9cessaire.<\/p><\/li>\n<li><p>Je sais qu'il est obligatoire de remplir le questionnaire m\u00e9dical joint \u00e0 ce formulaire selon la loi espagnole. Toutes les informations que j'ai fournies sont sinc\u00e8res, et j'accepte la responsabilit\u00e9 de toute cons\u00e9quence r\u00e9sultant de r\u00e9ponses inexactes ou de non-divulgation d'informations appropri\u00e9es.<\/p><\/li>\n<li><p>Je suis enti\u00e8rement responsable de la garde du mat\u00e9riel de location appartenant \u00e0 l'\u00e9cole et m'engage \u00e0 le restituer en cas de d\u00e9t\u00e9rioration par n\u00e9gligence, perte ou vol pendant l'activit\u00e9 contract\u00e9e.<\/p><\/li>\n<li><p>Je suis responsable de v\u00e9rifier le bon fonctionnement de l'\u00e9quipement que j'utiliserai pour plonger, que ce soit le mien ou lou\u00e9, ainsi que de v\u00e9rifier le bon remplissage de l'air dans la bouteille.<\/p><\/li>\n<li><p>Je comprends que la p\u00eache sous-marine, la collecte de la vie marine, des poissons, des coraux ou des coquillages (vivants ou morts) sont interdites par la loi. Certaines formes de vie marine peuvent causer des blessures corporelles, j'accepte donc de ne pas les toucher, les nourrir ou les harceler.<\/p>\n<p>Chez Scuba School Lanzarote, repr\u00e9sent\u00e9e l\u00e9galement par Luis Duque Garcia avec le num\u00e9ro d'identification 40981368Z, nous traitons les informations fournies dans le but de fournir les services demand\u00e9s et d'\u00e9mettre les factures correspondantes. Les donn\u00e9es fournies seront conserv\u00e9es aussi longtemps que dure la relation commerciale ou pendant les ann\u00e9es n\u00e9cessaires pour respecter les obligations l\u00e9gales. Les donn\u00e9es ne seront pas transmises \u00e0 des tiers sauf en cas d'obligation l\u00e9gale.<\/p>\n<p>En signant ce document, vous autorisez Scuba School Lanzarote \u00e0 utiliser vos donn\u00e9es dans le but de vous proposer de nouveaux services, promotions et communications li\u00e9es \u00e0 la plong\u00e9e. Vous avez le droit de confirmer si Scuba School Lanzarote traite correctement vos donn\u00e9es personnelles, donc le droit d'acc\u00e9der \u00e0 vos donn\u00e9es personnelles, de rectifier les informations inexactes ou de demander leur suppression lorsque les donn\u00e9es ne sont plus n\u00e9cessaires.<\/p>\n<p>Pendant la r\u00e9alisation des activit\u00e9s, des photos ou des enregistrements d'images peuvent \u00eatre r\u00e9alis\u00e9s, qui seront utilis\u00e9s ult\u00e9rieurement \u00e0 des fins promotionnelles, informatives ou \u00e9ducatives de la plong\u00e9e sous-marine et de l'\u00e9cole. En signant ce document, je consens \u00e0 la r\u00e9alisation et au traitement de ces images.<\/p>\n<\/li>\n<\/ol><\/div><\/div><div id=\"wpforms-1480-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-1480-field_45-container\" class=\"wpforms-field wpforms-field-signature margin-top-bg\" data-field-id=\"45\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_45\">Signature <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1480-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-1480-field_45-error\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-1480-field_45-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Effacer la 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\">Effacer la signature<\/div>\n\t\t\t<\/div><\/div><\/div><div id=\"wpforms-1480-field_21-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_21\">Date <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-1480-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-1480-field_21-error\" required><a title=\"Effacer la date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Effacer la date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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-1480-field_46\">Signature autoris\u00e9e <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1480-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-1480-field_46-error\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-1480-field_46-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Effacer la 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\">Effacer la signature<\/div>\n\t\t\t<\/div><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-field_256-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"256\"><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=\"1480\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2 last \" data-page=\"2\" style=\"display:none;\"><div id=\"wpforms-1480-field_70-container\" class=\"wpforms-field wpforms-field-html margin-top-bg\" data-field-id=\"70\"><div id=\"wpforms-1480-field_70\" aria-errormessage=\"wpforms-1480-field_70-error\"><h1>Examen M\u00e9dical du Plongeur<\/h1><h2>Questionnaire des participants<\/h2><\/div><\/div><div id=\"wpforms-1480-field_71-container\" class=\"wpforms-field wpforms-field-html margin-top-bg\" data-field-id=\"71\"><div id=\"wpforms-1480-field_71\" aria-errormessage=\"wpforms-1480-field_71-error\"><p>La plong\u00e9e sous-marine et l\u2019apn\u00e9e r\u00e9cr\u00e9ative n\u00e9cessitent une bonne sant\u00e9 physique et mentale. Il y a quelques conditions m\u00e9dicales qui peuvent \u00eatre dangereuses pendant la plong\u00e9e, \u00e9num\u00e9r\u00e9es ci-dessous. Ceux qui ont ou sont pr\u00e9dispos\u00e9s \u00e0 l\u2019une de ces conditions doivent \u00eatre examin\u00e9s par un m\u00e9decin. Ce questionnaire m\u00e9dical pour plongeurs fournit une base pour d\u00e9terminer si vous devez demander cette \u00e9valuation.<\/p>\n<p>Si vous avez des inqui\u00e9tudes concernant votre condition physique pour la plong\u00e9e qui ne sont pas reprises sur ce formulaire, consultez votre m\u00e9decin avant de plonger. Si vous vous sentez mal, \u00e9vitez de plonger. Si vous pensez avoir une maladie contagieuse, prot\u00e9gezvous et prot\u00e9gez les autres en ne participant pas \u00e0 la formation et\/ou aux activit\u00e9s de plong\u00e9e. Les r\u00e9f\u00e9rences \u00e0 la \u00abplong\u00e9e\u00bb sur ce formulaire englobent \u00e0 la fois la plong\u00e9e sous-marine de loisir et l\u2019apn\u00e9e. Ce formulaire est principalement con\u00e7u comme une \u00e9valuation m\u00e9dicale initiale pour les nouveaux plongeurs, mais convient \u00e9galement aux plongeurs qui suivent une formation continue. Pour votre s\u00e9curit\u00e9 et celle des autres personnes susceptibles de plonger avec vous, r\u00e9pondez honn\u00eatement \u00e0 toutes les questions.<\/p>\n<br \/>\n<\/div><\/div><div id=\"wpforms-1480-field_115-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"115\"><div id=\"wpforms-1480-field_115\" aria-errormessage=\"wpforms-1480-field_115-error\"><h3>Instructions<\/h3>\n<p>Remplissez ce questionnaire pr\u00e9alablement \u00e0 un cours de plong\u00e9e sous-marine ou d\u2019apn\u00e9e.<\/p>\n<p><b>Note:<\/b>  Si vous \u00eates enceinte ou tentez de devenir enceinte, ne plongez pas.<\/p><\/div><\/div><div id=\"wpforms-1480-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-1480-field_74-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"74\"><div id=\"wpforms-1480-field_74\" aria-errormessage=\"wpforms-1480-field_74-error\"><span class=\"numero-preg\">1<\/span><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1480-field_76-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"76\"><div id=\"wpforms-1480-field_76\" aria-errormessage=\"wpforms-1480-field_76-error\"><p>J'ai eu des probl\u00e8mes avec mes poumons, ma respiration, mon coeur et\/ou mon sang qui ont affect\u00e9 mes performances physiques ou mentales normales.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">J&#039;ai eu des probl\u00e8mes avec mes poumons, ma respiration, mon coeur et\/ou mon sang qui ont affect\u00e9 mes performances physiques ou mentales normales. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_77\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_77_1\" name=\"wpforms[fields][77]\" value=\"Oui\" aria-errormessage=\"wpforms-1480-field_77_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_77_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_77_2\" name=\"wpforms[fields][77]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_77_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_77_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_136\" aria-errormessage=\"wpforms-1480-field_136-error\"><p>Chirurgie thoracique, chirurgie cardiaque, chirurgie des valves cardiaques, dispositif m\u00e9dical implantable (par exemple, stent, stimulateur cardiaque, neurostimulateur), pneumothorax et\/ou maladie pulmonaire chronique.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Chirurgie thoracique, chirurgie cardiaque, chirurgie des valves cardiaques, dispositif m\u00e9dical implantable (par exemple, stent, stimulateur cardiaque, neurostimulateur), pneumothorax et\/ou maladie pulmonaire chronique. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_137\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_137_1\" name=\"wpforms[fields][137]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_137_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_137_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_137_2\" name=\"wpforms[fields][137]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_137_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_137_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_139\" aria-errormessage=\"wpforms-1480-field_139-error\"><p>Asthme, respiration sifflante, allergies graves, rhume des foins ou voies respiratoires congestionn\u00e9es au cours des 12 derniers mois, qui limitent mon activit\u00e9 physique \/ exercice.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Asthme, respiration sifflante, allergies graves, rhume des foins ou voies respiratoires congestionn\u00e9es au cours des 12 derniers mois, qui limitent mon activit\u00e9 physique \/ exercice. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_140\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_140_1\" name=\"wpforms[fields][140]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_140_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_140_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_140_2\" name=\"wpforms[fields][140]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_140_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_140_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_142\" aria-errormessage=\"wpforms-1480-field_142-error\"><p>Un probl\u00e8me ou une maladie touchant mon coeur tels que: angine de poitrine, douleur thoracique \u00e0 l\u2019effort, insuffisance cardiaque, oed\u00e8me pulmonaire d\u2019immersion, crise cardiaque ou accident vasculaire c\u00e9r\u00e9bral; ou: je prends des m\u00e9dicaments pour toute affection cardiaque.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Un probl\u00e8me ou une maladie touchant mon coeur tels que: angine de poitrine, douleur thoracique \u00e0 l\u2019effort, insuffisance cardiaque, oed\u00e8me pulmonaire d\u2019immersion, crise cardiaque ou accident vasculaire c\u00e9r\u00e9bral; ou: je prends des m\u00e9dicaments pour toute affection cardiaque. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_143\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_143_1\" name=\"wpforms[fields][143]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_143_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_143_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_143_2\" name=\"wpforms[fields][143]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_143_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_143_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_145\" aria-errormessage=\"wpforms-1480-field_145-error\"><p>Bronchite r\u00e9currente et toux actuelle au cours des 12 derniers mois; ou: on m\u2019a diagnostiqu\u00e9 d\u2019un emphys\u00e8me.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Bronchite r\u00e9currente et toux actuelle au cours des 12 derniers mois; ou: on m\u2019a diagnostiqu\u00e9 d\u2019un emphys\u00e8me. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_146\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_146_1\" name=\"wpforms[fields][146]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_146_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_146_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_146_2\" name=\"wpforms[fields][146]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_146_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_146_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_148\" aria-errormessage=\"wpforms-1480-field_148-error\"><p>Sympt\u00f4mes affectant mes poumons, ma respiration, mon coeur et\/ou mon sang au cours des 30 derniers jours et alt\u00e9rant mes performances physiques ou mentales.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Sympt\u00f4mes affectant mes poumons, ma respiration, mon coeur et\/ou mon sang au cours des 30 derniers jours et alt\u00e9rant mes performances physiques ou mentales. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_149\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_149_1\" name=\"wpforms[fields][149]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_149_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_149_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_149_2\" name=\"wpforms[fields][149]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_149_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_149_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-field_80-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"80\"><div id=\"wpforms-1480-field_80\" aria-errormessage=\"wpforms-1480-field_80-error\"><span class=\"numero-preg\">2<\/span><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1480-field_81-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"81\"><div id=\"wpforms-1480-field_81\" aria-errormessage=\"wpforms-1480-field_81-error\"><p>Je suis \u00e2g\u00e9 de plus de 45 ans.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Je suis \u00e2g\u00e9 de plus de 45 ans. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_82\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_82_1\" name=\"wpforms[fields][82]\" value=\"Oui\" aria-errormessage=\"wpforms-1480-field_82_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_82_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_82_2\" name=\"wpforms[fields][82]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_82_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_82_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_151\" aria-errormessage=\"wpforms-1480-field_151-error\"><p>Je fume ou j\u2019inhale de la nicotine par d\u2019autres moyens.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Je fume ou j\u2019inhale de la nicotine par d\u2019autres moyens. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_152\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_152_1\" name=\"wpforms[fields][152]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_152_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_152_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_152_2\" name=\"wpforms[fields][152]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_152_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_152_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_154\" aria-errormessage=\"wpforms-1480-field_154-error\"><p>J\u2019ai un taux de cholest\u00e9rol \u00e9lev\u00e9.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">J\u2019ai un taux de cholest\u00e9rol \u00e9lev\u00e9. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_155\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_155_1\" name=\"wpforms[fields][155]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_155_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_155_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_155_2\" name=\"wpforms[fields][155]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_155_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_155_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_157\" aria-errormessage=\"wpforms-1480-field_157-error\"><p>J\u2019ai une tension art\u00e9rielle \u00e9lev\u00e9e.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">J\u2019ai une tension art\u00e9rielle \u00e9lev\u00e9e. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_158\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_158_1\" name=\"wpforms[fields][158]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_158_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_158_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_158_2\" name=\"wpforms[fields][158]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_158_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_158_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_160\" aria-errormessage=\"wpforms-1480-field_160-error\"><p>J\u2019ai eu un parent proche d\u00e9c\u00e9d\u00e9 subitement ou d\u2019une maladie cardiaque ou d\u2019un accident vasculaire c\u00e9r\u00e9bral avant l\u2019\u00e2ge de 50 ans; ou: j\u2019ai des ant\u00e9c\u00e9dents familiaux de maladie cardiaque avant l\u2019\u00e2ge de 50 ans (y compris des troubles du rythme cardiaque, une maladie coronarienne ou une cardiomyopathie).<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">J\u2019ai eu un parent proche d\u00e9c\u00e9d\u00e9 subitement ou d\u2019une maladie cardiaque ou d\u2019un accident vasculaire c\u00e9r\u00e9bral avant l\u2019\u00e2ge de 50 ans; ou: j\u2019ai des ant\u00e9c\u00e9dents familiaux de maladie cardiaque avant l\u2019\u00e2ge de 50 ans (y compris des troubles du rythme cardiaque, une maladie coronarienne ou une cardiomyopathie). <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_161\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_161_1\" name=\"wpforms[fields][161]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_161_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_161_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_161_2\" name=\"wpforms[fields][161]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_161_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_161_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-field_84-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"84\"><div id=\"wpforms-1480-field_84\" aria-errormessage=\"wpforms-1480-field_84-error\"><span class=\"numero-preg\">3<\/span><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1480-field_85-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"85\"><div id=\"wpforms-1480-field_85\" aria-errormessage=\"wpforms-1480-field_85-error\"><p>J\u2019ai du mal \u00e0 faire des efforts physiques mod\u00e9r\u00e9s (par exemple, marcher 2 km en 15 minutes ou nager 200 m\u00e8tres sans me reposer), ou: je n\u2019ai pas pu participer \u00e0 une activit\u00e9 physique normale pour des raisons de forme physique ou de sant\u00e9 depuis 12 mois.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">J\u2019ai du mal \u00e0 faire des efforts physiques mod\u00e9r\u00e9s (par exemple, marcher 2 km en 15 minutes ou nager 200 m\u00e8tres sans me reposer), ou: je n\u2019ai pas pu participer \u00e0 une activit\u00e9 physique normale pour des raisons de forme physique ou de sant\u00e9 depuis 12 mois. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_86\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_86_1\" name=\"wpforms[fields][86]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_86_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_86_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_86_2\" name=\"wpforms[fields][86]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_86_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_86_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-field_88-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"88\"><div id=\"wpforms-1480-field_88\" aria-errormessage=\"wpforms-1480-field_88-error\"><span class=\"numero-preg\">4<\/span><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1480-field_89-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"89\"><div id=\"wpforms-1480-field_89\" aria-errormessage=\"wpforms-1480-field_89-error\"><p>J\u2019ai eu des probl\u00e8mes aux yeux, aux oreilles, aux conduites nasales ou sinus.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">J\u2019ai eu des probl\u00e8mes aux yeux, aux oreilles, aux conduites nasales ou sinus. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_90\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_90_1\" name=\"wpforms[fields][90]\" value=\"Oui\" aria-errormessage=\"wpforms-1480-field_90_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_90_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_90_2\" name=\"wpforms[fields][90]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_90_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_90_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_163\" aria-errormessage=\"wpforms-1480-field_163-error\"><p>Chirurgie des sinus au cours des 6 derniers mois.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Chirurgie des sinus au cours des 6 derniers mois. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_164\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_164_1\" name=\"wpforms[fields][164]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_164_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_164_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_164_2\" name=\"wpforms[fields][164]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_164_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_164_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_166\" aria-errormessage=\"wpforms-1480-field_166-error\"><p>Maladie ou chirurgie de l\u2019oreille, une perte auditive ou des probl\u00e8mes d\u2019\u00e9quilibre.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Maladie ou chirurgie de l\u2019oreille, une perte auditive ou des probl\u00e8mes d\u2019\u00e9quilibre. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_167\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_167_1\" name=\"wpforms[fields][167]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_167_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_167_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_167_2\" name=\"wpforms[fields][167]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_167_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_167_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_169\" aria-errormessage=\"wpforms-1480-field_169-error\"><p>Sinusite r\u00e9currente au cours des 12 derniers mois.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Sinusite r\u00e9currente au cours des 12 derniers mois. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_170\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_170_1\" name=\"wpforms[fields][170]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_170_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_170_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_170_2\" name=\"wpforms[fields][170]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_170_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_170_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_172\" aria-errormessage=\"wpforms-1480-field_172-error\"><p>Chirurgie oculaire au cours des 3 derniers mois.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Chirurgie oculaire au cours des 3 derniers mois. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_173\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_173_1\" name=\"wpforms[fields][173]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_173_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_173_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_173_2\" name=\"wpforms[fields][173]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_173_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_173_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-field_92-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"92\"><div id=\"wpforms-1480-field_92\" aria-errormessage=\"wpforms-1480-field_92-error\"><span class=\"numero-preg\">5<\/span><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1480-field_93-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"93\"><div id=\"wpforms-1480-field_93\" aria-errormessage=\"wpforms-1480-field_93-error\"><p>J\u2019ai subi une intervention chirurgicale au cours des 12 derniers mois; ou: j\u2019ai des probl\u00e8mes chroniques li\u00e9s \u00e0 une intervention chirurgicale ant\u00e9rieure.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">J\u2019ai subi une intervention chirurgicale au cours des 12 derniers mois; ou: j\u2019ai des probl\u00e8mes chroniques li\u00e9s \u00e0 une intervention chirurgicale ant\u00e9rieure. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_94\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_94_1\" name=\"wpforms[fields][94]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_94_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_94_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_94_2\" name=\"wpforms[fields][94]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_94_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_94_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-field_96-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"96\"><div id=\"wpforms-1480-field_96\" aria-errormessage=\"wpforms-1480-field_96-error\"><span class=\"numero-preg\">6<\/span><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1480-field_97-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"97\"><div id=\"wpforms-1480-field_97\" aria-errormessage=\"wpforms-1480-field_97-error\"><p>J\u2019ai perdu connaissance, j\u2019ai eu des migraines, des convulsions, un accident vasculaire c\u00e9r\u00e9bral, un traumatisme cr\u00e2nien important ou je souffre de l\u00e9sions ou maladies\nneurologiques persistantes.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">J\u2019ai perdu connaissance, j\u2019ai eu des migraines, des convulsions, un accident vasculaire c\u00e9r\u00e9bral, un traumatisme cr\u00e2nien important ou je souffre de l\u00e9sions ou maladies\nneurologiques persistantes. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_98\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_98_1\" name=\"wpforms[fields][98]\" value=\"Oui\" aria-errormessage=\"wpforms-1480-field_98_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_98_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_98_2\" name=\"wpforms[fields][98]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_98_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_98_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_175\" aria-errormessage=\"wpforms-1480-field_175-error\"><p>Traumatisme cr\u00e2nien avec perte de conscience au cours des 5 derni\u00e8res ann\u00e9es.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Traumatisme cr\u00e2nien avec perte de conscience au cours des 5 derni\u00e8res ann\u00e9es. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_176\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_176_1\" name=\"wpforms[fields][176]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_176_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_176_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_176_2\" name=\"wpforms[fields][176]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_176_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_176_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_178\" aria-errormessage=\"wpforms-1480-field_178-error\"><p>L\u00e9sion ou maladie neurologique persistante.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">L\u00e9sion ou maladie neurologique persistante. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_179\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_179_1\" name=\"wpforms[fields][179]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_179_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_179_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_179_2\" name=\"wpforms[fields][179]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_179_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_179_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_181\" aria-errormessage=\"wpforms-1480-field_181-error\"><p>Migraines r\u00e9currentes au cours des 12 derniers mois, ou: je prends des m\u00e9dicaments pour les pr\u00e9venir.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Migraines r\u00e9currentes au cours des 12 derniers mois, ou: je prends des m\u00e9dicaments pour les pr\u00e9venir. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_182\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_182_1\" name=\"wpforms[fields][182]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_182_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_182_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_182_2\" name=\"wpforms[fields][182]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_182_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_182_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_184\" aria-errormessage=\"wpforms-1480-field_184-error\"><p>Syncopes, absences ou \u00e9vanouissements (perte totale ou partielle de la conscience) au cours des 5 derni\u00e8res ann\u00e9es.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Syncopes, absences ou \u00e9vanouissements (perte totale ou partielle de la conscience) au cours des 5 derni\u00e8res ann\u00e9es. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_185\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_185_1\" name=\"wpforms[fields][185]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_185_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_185_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_185_2\" name=\"wpforms[fields][185]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_185_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_185_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_187\" aria-errormessage=\"wpforms-1480-field_187-error\"><p>\u00c9pilepsie, ou des convulsions; ou: je prends des m\u00e9dicaments pour les pr\u00e9venir.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">\u00c9pilepsie, ou des convulsions; ou: je prends des m\u00e9dicaments pour les pr\u00e9venir. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_188\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_188_1\" name=\"wpforms[fields][188]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_188_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_188_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_188_2\" name=\"wpforms[fields][188]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_188_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_188_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-field_100-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"100\"><div id=\"wpforms-1480-field_100\" aria-errormessage=\"wpforms-1480-field_100-error\"><span class=\"numero-preg\">7<\/span><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1480-field_101-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"101\"><div id=\"wpforms-1480-field_101\" aria-errormessage=\"wpforms-1480-field_101-error\"><p>Je suis actuellement en traitement (ou j'ai eu besoin d'un traitement au cours des cinq derni\u00e8res ann\u00e9es) pour des probl\u00e8mes psychologiques, des troubles de la personnalit\u00e9,\ndes crises de panique ou une d\u00e9pendance aux drogues ou \u00e0 l'alcool ; ou, on a diagnostiqu\u00e9 chez moi un trouble de l'apprentissage ou du d\u00e9veloppement.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Je suis actuellement en traitement (ou j&#039;ai eu besoin d&#039;un traitement au cours des cinq derni\u00e8res ann\u00e9es) pour des probl\u00e8mes psychologiques, des troubles de la personnalit\u00e9,\ndes crises de panique ou une d\u00e9pendance aux drogues ou \u00e0 l&#039;alcool ; ou, on a diagnostiqu\u00e9 chez moi un trouble de l&#039;apprentissage ou du d\u00e9veloppement. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_102\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_102_1\" name=\"wpforms[fields][102]\" value=\"Oui\" aria-errormessage=\"wpforms-1480-field_102_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_102_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_102_2\" name=\"wpforms[fields][102]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_102_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_102_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_190\" aria-errormessage=\"wpforms-1480-field_190-error\"><p>Des probl\u00e8mes de comportement, des probl\u00e8mes mentaux ou psychologiques n\u00e9cessitant un traitement m\u00e9dical et\/ou psychiatrique.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Des probl\u00e8mes de comportement, des probl\u00e8mes mentaux ou psychologiques n\u00e9cessitant un traitement m\u00e9dical et\/ou psychiatrique. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_191\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_191_1\" name=\"wpforms[fields][191]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_191_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_191_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_191_2\" name=\"wpforms[fields][191]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_191_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_191_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_193\" aria-errormessage=\"wpforms-1480-field_193-error\"><p>Une d\u00e9pression majeure, des id\u00e9es suicidaires, des attaques de panique, un trouble bipolaire non contr\u00e9 n\u00e9cessitant un traitement m\u00e9dicamenteux ou psychiatrique.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Une d\u00e9pression majeure, des id\u00e9es suicidaires, des attaques de panique, un trouble bipolaire non contr\u00e9 n\u00e9cessitant un traitement m\u00e9dicamenteux ou psychiatrique. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_194\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_194_1\" name=\"wpforms[fields][194]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_194_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_194_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_194_2\" name=\"wpforms[fields][194]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_194_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_194_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_196\" aria-errormessage=\"wpforms-1480-field_196-error\"><p>Il a \u00e9t\u00e9 diagnostiqu\u00e9 un probl\u00e8me de sant\u00e9 mentale ou un trouble de l'apprentissage\/du d\u00e9veloppement qui n\u00e9cessite des soins continus ou des am\u00e9nagements sp\u00e9ciaux.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Il a \u00e9t\u00e9 diagnostiqu\u00e9 un probl\u00e8me de sant\u00e9 mentale ou un trouble de l&#039;apprentissage\/du d\u00e9veloppement qui n\u00e9cessite des soins continus ou des am\u00e9nagements sp\u00e9ciaux. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_197\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_197_1\" name=\"wpforms[fields][197]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_197_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_197_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_197_2\" name=\"wpforms[fields][197]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_197_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_197_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_199\" aria-errormessage=\"wpforms-1480-field_199-error\"><p>Une d\u00e9pendance \u00e0 la drogue ou \u00e0 l\u2019alcool n\u00e9cessitant un traitement au cours des 5 derni\u00e8res ann\u00e9es.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Une d\u00e9pendance \u00e0 la drogue ou \u00e0 l\u2019alcool n\u00e9cessitant un traitement au cours des 5 derni\u00e8res ann\u00e9es. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_200\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_200_1\" name=\"wpforms[fields][200]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_200_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_200_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_200_2\" name=\"wpforms[fields][200]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_200_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_200_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-field_104-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"104\"><div id=\"wpforms-1480-field_104\" aria-errormessage=\"wpforms-1480-field_104-error\"><span class=\"numero-preg\">8<\/span><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1480-field_105-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"105\"><div id=\"wpforms-1480-field_105\" aria-errormessage=\"wpforms-1480-field_105-error\"><p>J\u2019ai eu des probl\u00e8mes de dos, une hernie, des ulc\u00e8res ou du diab\u00e8te.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">J\u2019ai eu des probl\u00e8mes de dos, une hernie, des ulc\u00e8res ou du diab\u00e8te. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_106\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_106_1\" name=\"wpforms[fields][106]\" value=\"Oui\" aria-errormessage=\"wpforms-1480-field_106_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_106_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_106_2\" name=\"wpforms[fields][106]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_106_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_106_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_202\" aria-errormessage=\"wpforms-1480-field_202-error\"><p>Des probl\u00e8mes de dos r\u00e9currents au cours des 6 derniers mois qui limitent mon activit\u00e9 quotidienne.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Des probl\u00e8mes de dos r\u00e9currents au cours des 6 derniers mois qui limitent mon activit\u00e9 quotidienne. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_203\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_203_1\" name=\"wpforms[fields][203]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_203_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_203_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_203_2\" name=\"wpforms[fields][203]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_203_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_203_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_206\" aria-errormessage=\"wpforms-1480-field_206-error\"><p>Une chirurgie du dos ou de la colonne vert\u00e9brale au cours des 12 derniers mois.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Une chirurgie du dos ou de la colonne vert\u00e9brale au cours des 12 derniers mois. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_207\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_207_1\" name=\"wpforms[fields][207]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_207_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_207_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_207_2\" name=\"wpforms[fields][207]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_207_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_207_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_209\" aria-errormessage=\"wpforms-1480-field_209-error\"><p>Du diab\u00e8te, contr\u00f4l\u00e9 par un m\u00e9dicament ou un r\u00e9gime, OU du diab\u00e8te de grossesse au cours des 12 derniers mois.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Du diab\u00e8te, contr\u00f4l\u00e9 par un m\u00e9dicament ou un r\u00e9gime, OU du diab\u00e8te de grossesse au cours des 12 derniers mois. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_210\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_210_1\" name=\"wpforms[fields][210]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_210_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_210_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_210_2\" name=\"wpforms[fields][210]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_210_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_210_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_212\" aria-errormessage=\"wpforms-1480-field_212-error\"><p>Une hernie non corrig\u00e9e qui limite mes capacit\u00e9s physiques.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Une hernie non corrig\u00e9e qui limite mes capacit\u00e9s physiques. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_213\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_213_1\" name=\"wpforms[fields][213]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_213_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_213_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_213_2\" name=\"wpforms[fields][213]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_213_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_213_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_215\" aria-errormessage=\"wpforms-1480-field_215-error\"><p>Des ulc\u00e8res cutan\u00e9s actifs ou non trait\u00e9s, des plaies chroniques ou une intervention chirurgicale pour ulc\u00e8re au cours des 6 derniers mois.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Des ulc\u00e8res cutan\u00e9s actifs ou non trait\u00e9s, des plaies chroniques ou une intervention chirurgicale pour ulc\u00e8re au cours des 6 derniers mois. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_216\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_216_1\" name=\"wpforms[fields][216]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_216_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_216_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_216_2\" name=\"wpforms[fields][216]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_216_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_216_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-field_108-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"108\"><div id=\"wpforms-1480-field_108\" aria-errormessage=\"wpforms-1480-field_108-error\"><span class=\"numero-preg\">9<\/span><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1480-field_109-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"109\"><div id=\"wpforms-1480-field_109\" aria-errormessage=\"wpforms-1480-field_109-error\"><p>J\u2019ai eu des probl\u00e8mes d\u2019estomac ou d\u2019intestin, y compris une diarrh\u00e9e r\u00e9cente.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">J\u2019ai eu des probl\u00e8mes d\u2019estomac ou d\u2019intestin, y compris une diarrh\u00e9e r\u00e9cente. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_110\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_110_1\" name=\"wpforms[fields][110]\" value=\"Oui\" aria-errormessage=\"wpforms-1480-field_110_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_110_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_110_2\" name=\"wpforms[fields][110]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_110_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_110_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_218\" aria-errormessage=\"wpforms-1480-field_218-error\"><p>Une chirurgie pour stomie (gastrostomie, colostomie ou n\u00e9phrostomise) sans avoir d\u00e9j\u00e0 l\u2019autorisation m\u00e9dicale pour nager ou faire des activit\u00e9s physiques.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Une chirurgie pour stomie (gastrostomie, colostomie ou n\u00e9phrostomise) sans avoir d\u00e9j\u00e0 l\u2019autorisation m\u00e9dicale pour nager ou faire des activit\u00e9s physiques. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_219\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_219_1\" name=\"wpforms[fields][219]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_219_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_219_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_219_2\" name=\"wpforms[fields][219]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_219_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_219_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_221\" aria-errormessage=\"wpforms-1480-field_221-error\"><p>Une d\u00e9shydratation n\u00e9cessitant une intervention m\u00e9dicale au cours des 7 derniers jours.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Une d\u00e9shydratation n\u00e9cessitant une intervention m\u00e9dicale au cours des 7 derniers jours. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_222\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_222_1\" name=\"wpforms[fields][222]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_222_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_222_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_222_2\" name=\"wpforms[fields][222]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_222_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_222_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_224\" aria-errormessage=\"wpforms-1480-field_224-error\"><p>Des ulc\u00e8res gastriques ou intestinaux actifs ou non trait\u00e9s; ou: traitement chirurgical de ces ulc\u00e8res au cours des 6 derniers mois.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Des ulc\u00e8res gastriques ou intestinaux actifs ou non trait\u00e9s; ou: traitement chirurgical de ces ulc\u00e8res au cours des 6 derniers mois. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_225\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_225_1\" name=\"wpforms[fields][225]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_225_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_225_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_225_2\" name=\"wpforms[fields][225]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_225_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_225_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_227\" aria-errormessage=\"wpforms-1480-field_227-error\"><p>Des br\u00fblures d\u2019estomac fr\u00e9quentes, r\u00e9gurgitation ou reflux gastro-oesophagien (RGO).<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Des br\u00fblures d\u2019estomac fr\u00e9quentes, r\u00e9gurgitation ou reflux gastro-oesophagien (RGO). <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_228\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_228_1\" name=\"wpforms[fields][228]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_228_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_228_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_228_2\" name=\"wpforms[fields][228]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_228_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_228_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_230\" aria-errormessage=\"wpforms-1480-field_230-error\"><p>Une colite ulc\u00e9reuse active ou non contr\u00e9e; ou: Maladie de Crohn.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Une colite ulc\u00e9reuse active ou non contr\u00e9e; ou: Maladie de Crohn. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_231\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_231_1\" name=\"wpforms[fields][231]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_231_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_231_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_231_2\" name=\"wpforms[fields][231]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_231_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_231_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-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-1480-field_233\" aria-errormessage=\"wpforms-1480-field_233-error\"><p>Une chirurgie bariatrique au cours des 12 derniers mois.<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Une chirurgie bariatrique au cours des 12 derniers mois. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_234\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_234_1\" name=\"wpforms[fields][234]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_234_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_234_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_234_2\" name=\"wpforms[fields][234]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_234_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_234_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-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-1480-field_112-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"112\"><div id=\"wpforms-1480-field_112\" aria-errormessage=\"wpforms-1480-field_112-error\"><span class=\"numero-preg\">10<\/span><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\" ><div id=\"wpforms-1480-field_113-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"113\"><div id=\"wpforms-1480-field_113\" aria-errormessage=\"wpforms-1480-field_113-error\"><p>Je prends des m\u00e9dicaments sur ordonnance (\u00e0 l'exception des contraceptifs ou des antipalud\u00e9ens autres que la m\u00e9floquine (Lariam).<\/p><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-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\">Je prends des m\u00e9dicaments sur ordonnance (\u00e0 l&#039;exception des contraceptifs ou des antipalud\u00e9ens autres que la m\u00e9floquine (Lariam). <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1480-field_114\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_114_1\" name=\"wpforms[fields][114]\" value=\"Oui *\" aria-errormessage=\"wpforms-1480-field_114_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_114_1\">Oui *<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1480-field_114_2\" name=\"wpforms[fields][114]\" value=\"Non\" aria-errormessage=\"wpforms-1480-field_114_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1480-field_114_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-1480-field_116-container\" class=\"wpforms-field wpforms-field-html margin-top-bg\" data-field-id=\"116\"><div id=\"wpforms-1480-field_116\" aria-errormessage=\"wpforms-1480-field_116-error\"><h3>Signature du participant<\/h3>\n<p><b>Si vous avez r\u00e9pondu NON aux 10 questions ci-dessus, un examen m\u00e9dical n'est pas n\u00e9cessaire. Veuillez lire et accepter la d\u00e9claration du participant ci-dessous en la signant et en la datant.<\/b><\/p>\n<p><b>Si vous avez r\u00e9pondu \u00abOui\u00bb dans une case marqu\u00e9e d'un \"*\", cela sera examin\u00e9 par le personnel du centre de plong\u00e9e et si nous avons besoin d'informations suppl\u00e9mentaires, nous vous contacterons.<\/b><\/p>\n<p><b>D\u00e9claration du participant: <\/b>J\u2019ai r\u00e9pondu honn\u00eatement \u00e0 toutes les questions et je comprends que j\u2019accepte la responsabilit\u00e9 des\ncons\u00e9quences r\u00e9sultant de toute question \u00e0 laquelle j\u2019ai r\u00e9pondu de mani\u00e8re inexacte, ou de mon omission de divulguer tout probl\u00e8me de\nsant\u00e9 existant ou pass\u00e9.<\/p><\/div><\/div><div id=\"wpforms-1480-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-1480-field_118-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"118\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_118\">Signature du participant <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1480-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-1480-field_118-error\" aria-describedby=\"wpforms-1480-field_118-description\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-1480-field_118-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Effacer la 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\">Effacer la signature<\/div>\n\t\t\t<\/div><\/div><div id=\"wpforms-1480-field_118-description\" class=\"wpforms-field-description\">(Ou, s'il s'agit d'un mineur, signature du parent\/tuteur du participant requise)<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><\/div><\/div><\/div><div id=\"wpforms-1480-field_133-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"133\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-field_122-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"122\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_122\">Pr\u00e9nom du participant<\/label><input type=\"text\" id=\"wpforms-1480-field_122\" class=\"wpforms-field-medium\" name=\"wpforms[fields][122]\" aria-errormessage=\"wpforms-1480-field_122-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-1480-field_119-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"119\"><label class=\"wpforms-field-label\" for=\"wpforms-1480-field_119\">Date <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div 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d&#8217;inscription[\/vc_column_text][\/vc_column][\/vc_row]<\/p>\n","protected":false},"author":7,"featured_media":0,"parent":1541,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-1491","page","type-page","status-publish"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.6 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Plongeur certifi\u00e9 - Scuba School Lanzarote<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/divessl.com\/fr\/formulaire-dinscription\/plongeur-certifie\/\" \/>\n<meta property=\"og:locale\" content=\"fr_FR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Plongeur certifi\u00e9 - Scuba School Lanzarote\" \/>\n<meta property=\"og:description\" content=\"[vc_row 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