{"id":1677,"date":"2025-01-10T17:19:31","date_gmt":"2025-01-10T22:19:31","guid":{"rendered":"https:\/\/ccoasc.com\/?page_id=1677"},"modified":"2025-01-23T18:09:33","modified_gmt":"2025-01-23T23:09:33","slug":"vestibular-medical-history-questionnaire","status":"publish","type":"page","link":"https:\/\/ccoasc.com\/vestibular-medical-history-questionnaire\/","title":{"rendered":"Vestibular Medical History Questionnaire"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});<\/script><div class=\"fuel-gf-wrapper\">\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_3' ><div id='gf_3' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_3'  action='\/wp-json\/wp\/v2\/pages\/1677#gf_3' data-formid='3' novalidate><div class=\"fuel-gf-alert\" role=\"alert\"><\/div>\n        <div id='gf_progressbar_wrapper_3' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>4<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_25' style='width:25%;'><span>25%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_3_1' class='gform_page ' data-js='page-field-id-0' >\n                                    <div class='gform_page_fields'><div id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_5\" class=\"gfield gfield--type-html gfield--input-type-html form-intro-instructions gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_5\" ><h3 class=\"pretest-heading\">PRETEST INSTRUCTIONS FOR VIDEO-NYSTAGMOGRAPHY (VNG)<\/h3>\n\n    <p class=\"pretest-pgh1\">You have been scheduled to have special testing to determine the cause of your symptoms. This information is\n    necessary for us to reach a diagnosis and determine the proper course of treatment for you. The balance system\n    consists of input from three pathways\u2014the eyes, or visual pathway; the proprioceptive pathway, or the sense of\n    where your body is in space; and the ears, or vestibular pathway.\n    <\/p>\n\n    <p class=\"pretest-pgh2\"><strong>VIDEO-NYSTAGMOGRAPHY:<\/strong> This test is done to determine the condition of the balance portion of the inner ear.\n        It helps in diagnosing the cause of dizziness and related conditions. The VNG takes about one hour. Please dress\n        comfortably and DO NOT WEAR EYE MAKEUP. This test consists of three parts\u2014a visual tracking test that measures movements of the eyes as they follow a target, positional testing and caloric tests that measure the functionality of your inner ear system.\n    <\/p>\n\n    <p class=\"pretest-pgh3\"><strong>48 HOURS PRIOR TO TESTING:<\/strong> Discontinue the following medications if new within the last year (consult your\n        prescribing physician if you have any concerns).\n    <\/p>\n\n    <p class=\"pretest-pgh4\"><strong>ANTI-NAUSEA:<\/strong> Compazine, Dramamine\u00ae, Phenergan, Atarax, Thorazine, etc.<\/p>\n\n    <p class=\"pretest-pgh5\"><strong>ANTI-VERTIGO:<\/strong> Antivert, Meclizine, Bonine\u00ae, Robinul, Dramamine\u00ae, MotionEaze, Unisom\u00ae, Scopolamine patch,\n        etc.<\/p>\n\n    <p class=\"pretest-pgh6\"><strong>ANTI-DEPRESSANTS, ANTI-ANXIETY:<\/strong> Xanax, Valium, Librium, Vistaril, Serax, Ativan, Librax, TRANXENE\u00ae, EFFEXOR XR\u00ae, Diazepam, Zoloft, Paxil, Wellbutrin, Lexapro, Prozac, Lorazepam, Cymbalta, Clonazepam, Ambien, Lunesta<\/p>\n\n    <p class=\"pretest-pgh7\"><strong>NARCOTICS &#038; BARBITUATES:<\/strong> Demerol, Phenaphen, TYLENOL\u00ae with Codeine, Darvocet, Oxycodone, Percocet<\/p>\n\n    <p class=\"pretest-pgh8\"><strong>ANTI-HISTAMINES:<\/strong> Actifed, BENADRYL\u00ae, Chlor-Trimeton, Dimetane, Disophrol, Teldrin, Triaminic\u00ae, Claritin\u00ae,\n        Clarinex, ZYRTEC\u00ae, Allegra\u00ae, Astelin and other over-the-counter cold remedies<\/p>\n\n    <p class=\"pretest-pgh9\"><strong>HERBS:<\/strong> Melatonin, Ephedra, Mu Huang, Ginkgo, St. John\u2019s Wort, Kava, Valerian<\/p>\n\n    <p class=\"pretest-pgh10\"><strong>ANY SUBSTANCE THAT AFFECTS THE CENTRAL NERVOUS SYSTEM<\/strong><\/p>\n\n    <p class=\"pretest-pgh11\"><strong>ALCOHOL<\/strong> in any quantity, including beer, wine and cough medicines with alcohol<\/p>\n\n    <p class=\"pretest-pgh12\"><strong>24 HOURS<\/strong> before testing, avoid caffeine (coffee, tea and sodas), tobacco products and cigarettes<\/p>\n\n    <p class=\"pretest-pgh13\"><strong>If you are unable to follow these instructions, please call us prior to the testing or inform us when you arrive for the\n        testing. It affects our interpretation of the test results.<\/strong><\/p>\n\n    <p class=\"pretest-pgh14\"><strong>DO NOT EAT ANYTHING FOUR HOURS BEFORE TESTING.<\/strong> If you have any questions, call the audiology\n        department at (843) 449-6449.<\/p><\/div><fieldset id=\"field_3_8\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown form-appointment-day field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_8\" ><legend class='gfield_label gform-field-label' >Your appointment day is:<\/legend><div id='input_3_8' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_3_8_1_container'><label for='input_3_8_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_8[]' id='input_3_8_1'   aria-required='false'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_3_8_2_container'><label for='input_3_8_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_8[]' id='input_3_8_2'   aria-required='false'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_3_8_3_container'><label for='input_3_8_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_8[]' id='input_3_8_3'   aria-required='false'  ><option value=''>Year<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><fieldset id=\"field_3_9\" class=\"gfield gfield--type-time gfield--input-type-time form-appointment-time field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_9\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Your appointment time is:<\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_3_9'>\n                            <input type='number' maxlength='2' name='input_9[]' id='input_3_9_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='false'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_3_9_1'>Hours<\/label>\n                        <\/div>\n                        <div class=\"below hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' maxlength='2' name='input_9[]' id='input_3_9_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='false'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_3_9_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <select name='input_9[]' id='input_3_9_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select> \n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_3_9_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/fieldset><div id=\"field_3_12\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_12\" ><div class=\"footer-form-contact\">\n    <p>3822 Mayfair Street, Myrtle Beach, SC 29577 | <Strong>Phone: (843) 449-6449<\/Strong><\/p>\n    <p>1120 Glenns Bay Road, Suite 117, Surfside Beach, SC 29575 | <Strong>Phone: (843) 215-1068<\/Strong><\/p>\n<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_3_15' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_2' class='gform_page' data-js='page-field-id-15' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_65\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no-border-heading gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_65\" ><h3 class=\"pretest-heading\">Vestibular Medical History Questionnaire<\/h3><\/div><fieldset id=\"field_3_16\" class=\"gfield gfield--type-name gfield--input-type-name form-fname-lname hipaa_forms_first_name hipaa_forms_last_name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_16\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_16'>\n                            \n                            <span id='input_3_16_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_16.3' id='input_3_16_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_16_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_16_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_16.6' id='input_3_16_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_16_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_17\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_17\" ><label class='gfield_label gform-field-label' for='input_3_17'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_17' id='input_3_17' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_17_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_17_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_17' class='gform_hidden' value='https:\/\/ccoasc.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_90\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full hipaa_forms_email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_90\" ><label class='gfield_label gform-field-label' for='input_3_90'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_90' id='input_3_90' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_3_18\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_18\" ><label class='gfield_label gform-field-label' for='input_3_18'>Today&#039;s Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_18' id='input_3_18' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_18_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_18_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_18' class='gform_hidden' value='https:\/\/ccoasc.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_19\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_19\" ><label class='gfield_label gform-field-label' for='input_3_19'>ENT\/Physician Referred<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_3_19' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_64\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no-border-heading gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_64\" ><p><strong>Initial Onset<\/strong><\/p><\/div><div id=\"field_3_20\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_20\" ><label class='gfield_label gform-field-label' for='input_3_20'>Describe what happened the first time you experienced dizzy\/imbalance symptoms:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_20' id='input_3_20' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_3_63\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no-border-heading gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_63\" ><p><strong>Symptoms<\/strong><\/p><\/div><fieldset id=\"field_3_21\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_21\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please check all that apply.<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_21'><div class='gchoice gchoice_3_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='Dizziness'  id='choice_3_21_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_21_1' id='label_3_21_1' class='gform-field-label gform-field-label--type-inline'>Dizziness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='Visual changes'  id='choice_3_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_21_2' id='label_3_21_2' class='gform-field-label gform-field-label--type-inline'>Visual changes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_21_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.3' type='checkbox'  value='Falling'  id='choice_3_21_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_21_3' id='label_3_21_3' class='gform-field-label gform-field-label--type-inline'>Falling<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_21_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.4' type='checkbox'  value='Hearing loss'  id='choice_3_21_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_21_4' id='label_3_21_4' class='gform-field-label gform-field-label--type-inline'>Hearing loss<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_21_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.5' type='checkbox'  value='Fatigue'  id='choice_3_21_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_21_5' id='label_3_21_5' class='gform-field-label gform-field-label--type-inline'>Fatigue<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_21_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.6' type='checkbox'  value='Nausea\/Vomiting'  id='choice_3_21_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_21_6' id='label_3_21_6' class='gform-field-label gform-field-label--type-inline'>Nausea\/Vomiting<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_21_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.7' type='checkbox'  value='Spinning'  id='choice_3_21_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_21_7' id='label_3_21_7' class='gform-field-label gform-field-label--type-inline'>Spinning<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_21_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.8' type='checkbox'  value='Double vision'  id='choice_3_21_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_21_8' id='label_3_21_8' class='gform-field-label gform-field-label--type-inline'>Double vision<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_21_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.9' type='checkbox'  value='Lightheadedness'  id='choice_3_21_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_21_9' id='label_3_21_9' class='gform-field-label gform-field-label--type-inline'>Lightheadedness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_21_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.11' type='checkbox'  value='Headache'  id='choice_3_21_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_21_11' id='label_3_21_11' class='gform-field-label gform-field-label--type-inline'>Headache<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_21_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.12' type='checkbox'  value='Brain fog'  id='choice_3_21_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_21_12' id='label_3_21_12' class='gform-field-label gform-field-label--type-inline'>Brain fog<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_21_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.13' type='checkbox'  value='Noise in ears'  id='choice_3_21_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_21_13' id='label_3_21_13' class='gform-field-label gform-field-label--type-inline'>Noise in ears<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_21_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.14' type='checkbox'  value='Fullness, pressure or pain in ears'  id='choice_3_21_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_21_14' id='label_3_21_14' class='gform-field-label gform-field-label--type-inline'>Fullness, pressure or pain in ears<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_21_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.15' type='checkbox'  value='Unsteadiness'  id='choice_3_21_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_21_15' id='label_3_21_15' class='gform-field-label gform-field-label--type-inline'>Unsteadiness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_21_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.16' type='checkbox'  value='Rocking\/Tilting'  id='choice_3_21_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_21_16' id='label_3_21_16' class='gform-field-label gform-field-label--type-inline'>Rocking\/Tilting<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_21_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.17' type='checkbox'  value='Fainting'  id='choice_3_21_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_21_17' id='label_3_21_17' class='gform-field-label gform-field-label--type-inline'>Fainting<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_62\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no-border-heading gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_62\" ><strong>History of Present Illness<\/strong><br>\nDescribe your current problem:<\/div><div id=\"field_3_22\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_22\" ><label class='gfield_label gform-field-label' for='input_3_22'>When did your problem start (date)?<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_3_22' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_24\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_24\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Was it associated with a related event (e.g., head injury)?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_24'><div class='gchoice gchoice_3_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='Yes'  id='choice_3_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_24_1' id='label_3_24_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='No'  id='choice_3_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_24_2' id='label_3_24_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_26\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_26\" ><label class='gfield_label gform-field-label' for='input_3_26'>If yes, please explain:<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_3_26' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_27\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_27\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Was the onset of your symptoms<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_27'><div class='gchoice gchoice_3_27_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.1' type='checkbox'  value='Sudden'  id='choice_3_27_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_27_1' id='label_3_27_1' class='gform-field-label gform-field-label--type-inline'>Sudden<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_27_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.2' type='checkbox'  value='Gradual'  id='choice_3_27_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_27_2' id='label_3_27_2' class='gform-field-label gform-field-label--type-inline'>Gradual<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_27_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.3' type='checkbox'  value='Overnight'  id='choice_3_27_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_27_3' id='label_3_27_3' class='gform-field-label gform-field-label--type-inline'>Overnight<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_27_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.4' type='checkbox'  value='Other'  id='choice_3_27_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_27_4' id='label_3_27_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_28\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_28\" ><label class='gfield_label gform-field-label' for='input_3_28'>Please describe:<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_3_28' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_29\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_29\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Are your symptoms:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_29'><div class='gchoice gchoice_3_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.1' type='checkbox'  value='Constant'  id='choice_3_29_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_29_1' id='label_3_29_1' class='gform-field-label gform-field-label--type-inline'>Constant<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_29_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.2' type='checkbox'  value='Variable (i.e., come and go in spells)'  id='choice_3_29_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_29_2' id='label_3_29_2' class='gform-field-label gform-field-label--type-inline'>Variable (i.e., come and go in spells)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_35\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_35\" ><label class='gfield_label gform-field-label' for='input_3_35'>The spell occurs every number of: Hours<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_3_35' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_36\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_36\" ><label class='gfield_label gform-field-label' for='input_3_36'>The spell occurs every number of: Days<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_3_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_37\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_37\" ><label class='gfield_label gform-field-label' for='input_3_37'>The spell occurs every number of: Weeks<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_3_37' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_38\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_38\" ><label class='gfield_label gform-field-label' for='input_3_38'>The spell occurs every number of: Months<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_3_38' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_39\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_39\" ><label class='gfield_label gform-field-label' for='input_3_39'>The spell occurs every number of: Years<\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_3_39' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_47\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_47\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >The spell lasts<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_47'><div class='gchoice gchoice_3_47_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.1' type='checkbox'  value='Seconds'  id='choice_3_47_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_47_1' id='label_3_47_1' class='gform-field-label gform-field-label--type-inline'>Seconds<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_47_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.2' type='checkbox'  value='Minutes'  id='choice_3_47_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_47_2' id='label_3_47_2' class='gform-field-label gform-field-label--type-inline'>Minutes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_47_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.3' type='checkbox'  value='Hours'  id='choice_3_47_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_47_3' id='label_3_47_3' class='gform-field-label gform-field-label--type-inline'>Hours<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_47_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.4' type='checkbox'  value='Days'  id='choice_3_47_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_47_4' id='label_3_47_4' class='gform-field-label gform-field-label--type-inline'>Days<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_44\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_44\" ><div class=\"footer-form-contact\">\n    <p>3822 Mayfair Street, Myrtle Beach, SC 29577 | <Strong>Phone: (843) 449-6449<\/Strong><\/p>\n    <p>1120 Glenns Bay Road, Suite 117, Surfside Beach, SC 29575 | <Strong>Phone: (843) 215-1068<\/Strong><\/p>\n<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_45' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' value='Previous'  \/> <input type='button' id='gform_next_button_3_45' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_3' class='gform_page' data-js='page-field-id-45' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_3_48\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_48\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you have any warning signs that a spell is about to happen?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_48'><div class='gchoice gchoice_3_48_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.1' type='checkbox'  value='Yes'  id='choice_3_48_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_48_1' id='label_3_48_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_48_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.2' type='checkbox'  value='No'  id='choice_3_48_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_48_2' id='label_3_48_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_49\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_49\" ><label class='gfield_label gform-field-label' for='input_3_49'>If yes, please describe:<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_3_49' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_50\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_50\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Are you completely free of symptoms between spells?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_50'><div class='gchoice gchoice_3_50_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.1' type='checkbox'  value='Yes'  id='choice_3_50_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_50_1' id='label_3_50_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_50_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.2' type='checkbox'  value='No'  id='choice_3_50_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_50_2' id='label_3_50_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_51\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_51\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do your symptoms occur when changing positions?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_51'><div class='gchoice gchoice_3_51_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.1' type='checkbox'  value='Yes'  id='choice_3_51_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_51_1' id='label_3_51_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_51_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.2' type='checkbox'  value='No'  id='choice_3_51_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_51_2' id='label_3_51_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_52\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_52\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >If yes, check all that apply:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_52'><div class='gchoice gchoice_3_52_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.1' type='checkbox'  value='Rolling your body to the left'  id='choice_3_52_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_52_1' id='label_3_52_1' class='gform-field-label gform-field-label--type-inline'>Rolling your body to the left<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_52_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.2' type='checkbox'  value='Rolling your body to the right'  id='choice_3_52_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_52_2' id='label_3_52_2' class='gform-field-label gform-field-label--type-inline'>Rolling your body to the right<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_52_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.3' type='checkbox'  value='Moving from a lying to a sitting position'  id='choice_3_52_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_52_3' id='label_3_52_3' class='gform-field-label gform-field-label--type-inline'>Moving from a lying to a sitting position<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_52_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.4' type='checkbox'  value='Looking up with your head back'  id='choice_3_52_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_52_4' id='label_3_52_4' class='gform-field-label gform-field-label--type-inline'>Looking up with your head back<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_52_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.5' type='checkbox'  value='Turning head side to side while sitting\/standing'  id='choice_3_52_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_52_5' id='label_3_52_5' class='gform-field-label gform-field-label--type-inline'>Turning head side to side while sitting\/standing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_52_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.6' type='checkbox'  value='Bending over with your head down'  id='choice_3_52_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_52_6' id='label_3_52_6' class='gform-field-label gform-field-label--type-inline'>Bending over with your head down<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_53\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_53\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Is there anything that makes your symptoms better?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_53'><div class='gchoice gchoice_3_53_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.1' type='checkbox'  value='Yes'  id='choice_3_53_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_53_1' id='label_3_53_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_53_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.2' type='checkbox'  value='No'  id='choice_3_53_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_53_2' id='label_3_53_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_54\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_54\" ><label class='gfield_label gform-field-label' for='input_3_54'>If yes, please explain:<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_3_54' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_55\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_55\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Is there anything that makes your symptoms worse?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_55'><div class='gchoice gchoice_3_55_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.1' type='checkbox'  value='Yes'  id='choice_3_55_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_55_1' id='label_3_55_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_55_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.2' type='checkbox'  value='No'  id='choice_3_55_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_55_2' id='label_3_55_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_56\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_56\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >If yes, check all that apply:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_56'><div class='gchoice gchoice_3_56_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.1' type='checkbox'  value='Moving your head'  id='choice_3_56_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_1' id='label_3_56_1' class='gform-field-label gform-field-label--type-inline'>Moving your head<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_56_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.2' type='checkbox'  value='Riding\/Driving in a car'  id='choice_3_56_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_2' id='label_3_56_2' class='gform-field-label gform-field-label--type-inline'>Riding\/Driving in a car<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_56_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.3' type='checkbox'  value='Loud sounds'  id='choice_3_56_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_3' id='label_3_56_3' class='gform-field-label gform-field-label--type-inline'>Loud sounds<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_56_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.4' type='checkbox'  value='Standing up'  id='choice_3_56_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_4' id='label_3_56_4' class='gform-field-label gform-field-label--type-inline'>Standing up<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_56_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.5' type='checkbox'  value='Time of day'  id='choice_3_56_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_5' id='label_3_56_5' class='gform-field-label gform-field-label--type-inline'>Time of day<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_56_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.6' type='checkbox'  value='Physical activity or exercise'  id='choice_3_56_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_6' id='label_3_56_6' class='gform-field-label gform-field-label--type-inline'>Physical activity or exercise<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_56_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.7' type='checkbox'  value='Large crowds or busy environments'  id='choice_3_56_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_7' id='label_3_56_7' class='gform-field-label gform-field-label--type-inline'>Large crowds or busy environments<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_56_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.8' type='checkbox'  value='Coughing, blowing nose'  id='choice_3_56_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_8' id='label_3_56_8' class='gform-field-label gform-field-label--type-inline'>Coughing, blowing nose<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_56_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.9' type='checkbox'  value='Eating certain foods'  id='choice_3_56_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_9' id='label_3_56_9' class='gform-field-label gform-field-label--type-inline'>Eating certain foods<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_56_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.11' type='checkbox'  value='Stress'  id='choice_3_56_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_11' id='label_3_56_11' class='gform-field-label gform-field-label--type-inline'>Stress<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_57\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_57\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >When you have symptoms, do you need to support yourself to stand or walk?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_57'><div class='gchoice gchoice_3_57_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.1' type='checkbox'  value='Yes'  id='choice_3_57_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_57_1' id='label_3_57_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_57_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.2' type='checkbox'  value='No'  id='choice_3_57_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_57_2' id='label_3_57_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_58\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_58\" ><label class='gfield_label gform-field-label' for='input_3_58'>If yes, how do you support yourself?<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_3_58' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_59\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_59\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Have you ever fallen as a result of your current problem?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_59'><div class='gchoice gchoice_3_59_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.1' type='checkbox'  value='Yes'  id='choice_3_59_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_59_1' id='label_3_59_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_59_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.2' type='checkbox'  value='No'  id='choice_3_59_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_59_2' id='label_3_59_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_60\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_60\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you have a history of any of the following? Check all that apply.<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_60'><div class='gchoice gchoice_3_60_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.1' type='checkbox'  value='Migraines'  id='choice_3_60_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_60_1' id='label_3_60_1' class='gform-field-label gform-field-label--type-inline'>Migraines<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_60_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.2' type='checkbox'  value='Multiple sclerosis'  id='choice_3_60_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_60_2' id='label_3_60_2' class='gform-field-label gform-field-label--type-inline'>Multiple sclerosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_60_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.3' type='checkbox'  value='Panic attacks\/Anxiety'  id='choice_3_60_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_60_3' id='label_3_60_3' class='gform-field-label gform-field-label--type-inline'>Panic attacks\/Anxiety<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_60_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.4' type='checkbox'  value='Glaucoma'  id='choice_3_60_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_60_4' id='label_3_60_4' class='gform-field-label gform-field-label--type-inline'>Glaucoma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_60_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.5' type='checkbox'  value='Seizures'  id='choice_3_60_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_60_5' id='label_3_60_5' class='gform-field-label gform-field-label--type-inline'>Seizures<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_60_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.6' type='checkbox'  value='Neuropathy'  id='choice_3_60_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_60_6' id='label_3_60_6' class='gform-field-label gform-field-label--type-inline'>Neuropathy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_60_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.7' type='checkbox'  value='Depression'  id='choice_3_60_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_60_7' id='label_3_60_7' class='gform-field-label gform-field-label--type-inline'>Depression<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_60_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.8' type='checkbox'  value='Macular degeneration'  id='choice_3_60_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_60_8' id='label_3_60_8' class='gform-field-label gform-field-label--type-inline'>Macular degeneration<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_60_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.9' type='checkbox'  value='Tumor'  id='choice_3_60_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_60_9' id='label_3_60_9' class='gform-field-label gform-field-label--type-inline'>Tumor<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_60_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.11' type='checkbox'  value='Congestive heart failure'  id='choice_3_60_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_60_11' id='label_3_60_11' class='gform-field-label gform-field-label--type-inline'>Congestive heart failure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_60_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.12' type='checkbox'  value='Cervical spine arthritis'  id='choice_3_60_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_60_12' id='label_3_60_12' class='gform-field-label gform-field-label--type-inline'>Cervical spine arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_60_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.13' type='checkbox'  value='Parkinson\u2019s disease'  id='choice_3_60_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_60_13' id='label_3_60_13' class='gform-field-label gform-field-label--type-inline'>Parkinson\u2019s disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_60_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.14' type='checkbox'  value='Stroke'  id='choice_3_60_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_60_14' id='label_3_60_14' class='gform-field-label gform-field-label--type-inline'>Stroke<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_60_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.15' type='checkbox'  value='Concussion'  id='choice_3_60_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_60_15' id='label_3_60_15' class='gform-field-label gform-field-label--type-inline'>Concussion<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_60_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.16' type='checkbox'  value='Diabetes mellitus'  id='choice_3_60_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_60_16' id='label_3_60_16' class='gform-field-label gform-field-label--type-inline'>Diabetes mellitus<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_60_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.17' type='checkbox'  value='Ataxia'  id='choice_3_60_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_60_17' id='label_3_60_17' class='gform-field-label gform-field-label--type-inline'>Ataxia<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_61\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_61\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Has there been a recent change in your vision, including contacts or glasses?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_61'><div class='gchoice gchoice_3_61_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.1' type='checkbox'  value='Yes'  id='choice_3_61_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_61_1' id='label_3_61_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_61_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.2' type='checkbox'  value='No'  id='choice_3_61_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_61_2' id='label_3_61_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_66\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full no-border-heading gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_66\" ><p>Describe any ear-related symptoms.<\/p><\/div><fieldset id=\"field_3_68\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_68\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you have any difficulty with hearing?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_68'><div class='gchoice gchoice_3_68_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.1' type='checkbox'  value='Yes'  id='choice_3_68_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_68_1' id='label_3_68_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_68_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.2' type='checkbox'  value='No'  id='choice_3_68_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_68_2' id='label_3_68_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_69\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_69\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >If yes, which ear(s)?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_69'><div class='gchoice gchoice_3_69_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.1' type='checkbox'  value='Left'  id='choice_3_69_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_69_1' id='label_3_69_1' class='gform-field-label gform-field-label--type-inline'>Left<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_69_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.2' type='checkbox'  value='Right'  id='choice_3_69_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_69_2' id='label_3_69_2' class='gform-field-label gform-field-label--type-inline'>Right<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_69_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.3' type='checkbox'  value='Both'  id='choice_3_69_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_69_3' id='label_3_69_3' class='gform-field-label gform-field-label--type-inline'>Both<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_70\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_70\" ><label class='gfield_label gform-field-label' for='input_3_70'>When did this start?<\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_3_70' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_71\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_71\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do your ear symptoms occur at the same time as your dizziness\/imbalance symptoms?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_71'><div class='gchoice gchoice_3_71_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.1' type='checkbox'  value='Yes'  id='choice_3_71_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_71_1' id='label_3_71_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_71_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.2' type='checkbox'  value='No'  id='choice_3_71_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_71_2' id='label_3_71_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_72\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_72\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >When you are walking, do you:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_72'><div class='gchoice gchoice_3_72_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.1' type='checkbox'  value='Veer left?'  id='choice_3_72_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_72_1' id='label_3_72_1' class='gform-field-label gform-field-label--type-inline'>Veer left?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_72_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.2' type='checkbox'  value='Veer right?'  id='choice_3_72_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_72_2' id='label_3_72_2' class='gform-field-label gform-field-label--type-inline'>Veer right?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_72_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.3' type='checkbox'  value='Remain on a straight path?'  id='choice_3_72_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_72_3' id='label_3_72_3' class='gform-field-label gform-field-label--type-inline'>Remain on a straight path?<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_73' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' value='Previous'  \/> <input type='button' id='gform_next_button_3_73' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_4' class='gform_page' data-js='page-field-id-73' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_3_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_74\" class=\"gfield gfield--type-html gfield--input-type-html no-border-heading gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_74\" ><p><strong>Habits<\/strong><\/p><\/div><div id=\"field_3_75\" class=\"gfield gfield--type-html gfield--input-type-html no-border-heading gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_75\" ><p>Please describe your habits in regard to the following substances:<\/p><\/div><fieldset id=\"field_3_76\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_76\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Caffeine<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_76'><div class='gchoice gchoice_3_76_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.1' type='checkbox'  value='I do not consume caffeine'  id='choice_3_76_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_76_1' id='label_3_76_1' class='gform-field-label gform-field-label--type-inline'>I do not consume caffeine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_76_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.2' type='checkbox'  value='I consume caffeine.'  id='choice_3_76_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_76_2' id='label_3_76_2' class='gform-field-label gform-field-label--type-inline'>I consume caffeine.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_78\" class=\"gfield gfield--type-name gfield--input-type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_78\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Caffeine Frequency<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_3_78'>\n                            \n                            <span id='input_3_78_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_78.3' id='input_3_78_3' value=''   aria-required='false'   placeholder='Amount'  \/>\n                                                    <label for='input_3_78_3' class='gform-field-label gform-field-label--type-sub '>I drink<\/label>\n                                                <\/span>\n                            <span id='input_3_78_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_78.4' id='input_3_78_4' value=''   aria-required='false'   placeholder='Type'  \/>\n                                                    <label for='input_3_78_4' class='gform-field-label gform-field-label--type-sub '>cups of (e.g., coffee)<\/label>\n                                                <\/span>\n                            <span id='input_3_78_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_78.6' id='input_3_78_6' value=''   aria-required='false'   placeholder='Frequency'  \/>\n                                                    <label for='input_3_78_6' class='gform-field-label gform-field-label--type-sub '>per (time period)<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_3_79\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_79\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Tobacco<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_79'><div class='gchoice gchoice_3_79_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_79.1' type='checkbox'  value='I do not consume tobacco.'  id='choice_3_79_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_79_1' id='label_3_79_1' class='gform-field-label gform-field-label--type-inline'>I do not consume tobacco.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_79_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_79.2' type='checkbox'  value='I consume tobacco.'  id='choice_3_79_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_79_2' id='label_3_79_2' class='gform-field-label gform-field-label--type-inline'>I consume tobacco.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_80\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_80\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Tobacco Frequency<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_3_80'>\n                            \n                            <span id='input_3_80_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_80.3' id='input_3_80_3' value=''   aria-required='false'   placeholder='Amount'  \/>\n                                                    <label for='input_3_80_3' class='gform-field-label gform-field-label--type-sub '>I smoke\/chew<\/label>\n                                                <\/span>\n                            <span id='input_3_80_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_80.4' id='input_3_80_4' value=''   aria-required='false'   placeholder='Type'  \/>\n                                                    <label for='input_3_80_4' class='gform-field-label gform-field-label--type-sub '>(amount) of (product)<\/label>\n                                                <\/span>\n                            <span id='input_3_80_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_80.6' id='input_3_80_6' value=''   aria-required='false'   placeholder='Frequency'  \/>\n                                                    <label for='input_3_80_6' class='gform-field-label gform-field-label--type-sub '>per (time period)<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_3_81\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_81\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Alcohol<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_81'><div class='gchoice gchoice_3_81_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.1' type='checkbox'  value='I do not consume alcohol.'  id='choice_3_81_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_81_1' id='label_3_81_1' class='gform-field-label gform-field-label--type-inline'>I do not consume alcohol.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_81_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.2' type='checkbox'  value='I consume alcohol.'  id='choice_3_81_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_81_2' id='label_3_81_2' class='gform-field-label gform-field-label--type-inline'>I consume alcohol.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_82\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_82\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Alcohol Frequency<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_3_82'>\n                            \n                            <span id='input_3_82_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_82.3' id='input_3_82_3' value=''   aria-required='false'   placeholder='Amount'  \/>\n                                                    <label for='input_3_82_3' class='gform-field-label gform-field-label--type-sub '>I drink<\/label>\n                                                <\/span>\n                            <span id='input_3_82_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_82.4' id='input_3_82_4' value=''   aria-required='false'   placeholder='Type'  \/>\n                                                    <label for='input_3_82_4' class='gform-field-label gform-field-label--type-sub '>glasses of (e.g., wine)<\/label>\n                                                <\/span>\n                            <span id='input_3_82_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_82.6' id='input_3_82_6' value=''   aria-required='false'   placeholder='Frequency'  \/>\n                                                    <label for='input_3_82_6' class='gform-field-label gform-field-label--type-sub '>per (time period)<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_3_83\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_83\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Recreational drug use<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_83'><div class='gchoice gchoice_3_83_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_83.1' type='checkbox'  value='I do not use drugs.'  id='choice_3_83_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_83_1' id='label_3_83_1' class='gform-field-label gform-field-label--type-inline'>I do not use drugs.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_83_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_83.2' type='checkbox'  value='I use drugs.'  id='choice_3_83_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_83_2' id='label_3_83_2' class='gform-field-label gform-field-label--type-inline'>I use drugs.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_85\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_85\" ><label class='gfield_label gform-field-label' for='input_3_85'>I use: If selected &#039;I use drugs&#039;<\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_3_85' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_86\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_86\" ><label class='gfield_label gform-field-label' for='input_3_86'>How many times per day? If selected &#039;I use drugs&#039;<\/label><div class='ginput_container ginput_container_text'><input name='input_86' id='input_3_86' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_87\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_87\" ><label class='gfield_label gform-field-label' for='input_3_87'>For how many years? If selected &#039;I use drugs&#039;<\/label><div class='ginput_container ginput_container_text'><input name='input_87' id='input_3_87' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_88\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_88\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Medications<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_88'><div class='gchoice gchoice_3_88_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.1' type='checkbox'  value='I do not take any medications.'  id='choice_3_88_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_88_1' id='label_3_88_1' class='gform-field-label gform-field-label--type-inline'>I do not take any medications.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_88_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.2' type='checkbox'  value='I take medications.'  id='choice_3_88_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_88_2' id='label_3_88_2' class='gform-field-label gform-field-label--type-inline'>I take medications.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_89\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_89\" ><label class='gfield_label gform-field-label' for='input_3_89'>I take the following medications. 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