{"id":1685,"date":"2025-01-10T19:02:54","date_gmt":"2025-01-11T00:02:54","guid":{"rendered":"https:\/\/ccoasc.com\/?page_id=1685"},"modified":"2025-01-23T18:09:37","modified_gmt":"2025-01-23T23:09:37","slug":"allergy-questionnaire","status":"publish","type":"page","link":"https:\/\/ccoasc.com\/allergy-questionnaire\/","title":{"rendered":"Allergy 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_chrome gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_4' ><div id='gf_4' 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_4'  action='\/wp-json\/wp\/v2\/pages\/1685#gf_4' data-formid='4' novalidate><div class=\"fuel-gf-alert\" role=\"alert\"><\/div>\n        <div id='gf_progressbar_wrapper_4' 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'>2<\/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_50' style='width:50%;'><span>50%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_4_1' class='gform_page ' data-js='page-field-id-0' >\n                                    <div class='gform_page_fields'><div id='gform_fields_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_4_32\" 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_4_32\" ><h3 class=\"pretest-heading\">Allergy Questionnaire<\/h3><\/div><fieldset id=\"field_4_1\" 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_4_1\" ><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_4_1'>\n                            \n                            <span id='input_4_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_4_1_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_4_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_4_1_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_4_34\" 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_4_34\" ><label class='gfield_label gform-field-label' for='input_4_34'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_34' id='input_4_34' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_4_3\" 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_4_3\" ><label class='gfield_label gform-field-label' for='input_4_3'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_3' id='input_4_3' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_3_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_3_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_3' class='gform_hidden' value='https:\/\/ccoasc.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_4_4\" 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_4_4\" ><label class='gfield_label gform-field-label' for='input_4_4'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_4' id='input_4_4' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_4_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_4_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_4' class='gform_hidden' value='https:\/\/ccoasc.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_4_6\" 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_4_6\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Have you been allergy tested before?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_6'><div class='gchoice gchoice_4_6_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.1' type='checkbox'  value='Yes'  id='choice_4_6_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_6_1' id='label_4_6_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_4_6_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.2' type='checkbox'  value='No'  id='choice_4_6_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_6_2' id='label_4_6_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_4_7\" 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_4_7\" ><label class='gfield_label gform-field-label' for='input_4_7'>If yes: When?<\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_4_7' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_8\" 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_4_8\" ><label class='gfield_label gform-field-label' for='input_4_8'>If yes: Where?<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_4_8' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_9\" 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_4_9\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >2. Please choose all of the symptoms that you experience:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_9'><div class='gchoice gchoice_4_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.1' type='checkbox'  value='Wheezing'  id='choice_4_9_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_9_1' id='label_4_9_1' class='gform-field-label gform-field-label--type-inline'>Wheezing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_9_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.2' type='checkbox'  value='Sneezing'  id='choice_4_9_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_9_2' id='label_4_9_2' class='gform-field-label gform-field-label--type-inline'>Sneezing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_9_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.3' type='checkbox'  value='Congestion'  id='choice_4_9_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_9_3' id='label_4_9_3' class='gform-field-label gform-field-label--type-inline'>Congestion<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_9_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.4' type='checkbox'  value='Postnasal drainage'  id='choice_4_9_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_9_4' id='label_4_9_4' class='gform-field-label gform-field-label--type-inline'>Postnasal drainage<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_9_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.5' type='checkbox'  value='Loss of voice'  id='choice_4_9_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_9_5' id='label_4_9_5' class='gform-field-label gform-field-label--type-inline'>Loss of voice<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_9_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.6' type='checkbox'  value='Hearing loss'  id='choice_4_9_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_9_6' id='label_4_9_6' 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_4_9_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.7' type='checkbox'  value='Shortness of breath'  id='choice_4_9_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_9_7' id='label_4_9_7' class='gform-field-label gform-field-label--type-inline'>Shortness of breath<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_9_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.8' type='checkbox'  value='Loss of smell'  id='choice_4_9_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_9_8' id='label_4_9_8' class='gform-field-label gform-field-label--type-inline'>Loss of smell<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_9_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.9' type='checkbox'  value='Bad breath'  id='choice_4_9_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_9_9' id='label_4_9_9' class='gform-field-label gform-field-label--type-inline'>Bad breath<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_9_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.11' type='checkbox'  value='Headaches'  id='choice_4_9_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_9_11' id='label_4_9_11' class='gform-field-label gform-field-label--type-inline'>Headaches<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_9_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.12' type='checkbox'  value='Snoring'  id='choice_4_9_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_9_12' id='label_4_9_12' class='gform-field-label gform-field-label--type-inline'>Snoring<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_9_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.13' type='checkbox'  value='Fatigue'  id='choice_4_9_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_9_13' id='label_4_9_13' class='gform-field-label gform-field-label--type-inline'>Fatigue<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_9_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.14' type='checkbox'  value='Runny nose'  id='choice_4_9_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_9_14' id='label_4_9_14' class='gform-field-label gform-field-label--type-inline'>Runny nose<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_9_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.15' type='checkbox'  value='Eczema'  id='choice_4_9_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_9_15' id='label_4_9_15' class='gform-field-label gform-field-label--type-inline'>Eczema<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_9_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.16' type='checkbox'  value='Frequent clearing of throat'  id='choice_4_9_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_9_16' id='label_4_9_16' class='gform-field-label gform-field-label--type-inline'>Frequent clearing of throat<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_10\" 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_4_10\" ><label class='gfield_label gform-field-label' for='input_4_10'>3. Are your symptoms seasonal or year-round?<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_4_10' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_12\" 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_4_12\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do your symptoms flare up often?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_12'><div class='gchoice gchoice_4_12_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.1' type='checkbox'  value='Yes'  id='choice_4_12_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_12_1' id='label_4_12_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_4_12_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.2' type='checkbox'  value='No'  id='choice_4_12_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_12_2' id='label_4_12_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_4_13\" 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_4_13\" ><label class='gfield_label gform-field-label' for='input_4_13'>How long do your flare-ups last?<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_4_13' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_14\" 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_4_14\" ><label class='gfield_label gform-field-label' for='input_4_14'>Are your symptoms worse during a certain time of day?<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_4_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_15\" 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_4_15\" ><label class='gfield_label gform-field-label' for='input_4_15'>Are your symptoms worse during certain seasons?<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_4_15' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_16\" 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_4_16\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you have upper respiratory infections more than three times a year?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_16'><div class='gchoice gchoice_4_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='Yes'  id='choice_4_16_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_16_1' id='label_4_16_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_4_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='No'  id='choice_4_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_16_2' id='label_4_16_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_4_17\" 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_4_17\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you have pets?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_17'><div class='gchoice gchoice_4_17_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.1' type='checkbox'  value='Yes'  id='choice_4_17_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_17_1' id='label_4_17_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_4_17_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.2' type='checkbox'  value='No'  id='choice_4_17_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_17_2' id='label_4_17_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_4_18\" 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_4_18\" ><label class='gfield_label gform-field-label' for='input_4_18'>If so, what kind?<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_4_18' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_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_4_19\" ><label class='gfield_label gform-field-label' for='input_4_19'>How long have you lived in the area?<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_4_19' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_20\" 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_4_20\" ><label class='gfield_label gform-field-label' for='input_4_20'>How long have you lived at your current address?<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_4_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_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_4_21\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Did you have allergy or asthma symptoms in your previous residence or state?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_21'><div class='gchoice gchoice_4_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='Yes'  id='choice_4_21_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_21_1' id='label_4_21_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_4_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='No'  id='choice_4_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_21_2' id='label_4_21_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_4_22\" 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_4_22\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you have a family history of asthma?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_22'><div class='gchoice gchoice_4_22_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.1' type='checkbox'  value='Yes'  id='choice_4_22_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_22_1' id='label_4_22_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_4_22_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.2' type='checkbox'  value='No'  id='choice_4_22_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_22_2' id='label_4_22_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_4_23\" 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_4_23\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Were you diagnosed with asthma as a child?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_23'><div class='gchoice gchoice_4_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='Yes'  id='choice_4_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_23_1' id='label_4_23_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_4_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='No'  id='choice_4_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_23_2' id='label_4_23_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_4_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_4_24\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please choose all the medications below that you have taken in the last year:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_24'><div class='gchoice gchoice_4_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='Inhalers'  id='choice_4_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_24_1' id='label_4_24_1' class='gform-field-label gform-field-label--type-inline'>Inhalers<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='Antihistamines'  id='choice_4_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_24_2' id='label_4_24_2' class='gform-field-label gform-field-label--type-inline'>Antihistamines<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_24_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.3' type='checkbox'  value='Eye drops'  id='choice_4_24_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_24_3' id='label_4_24_3' class='gform-field-label gform-field-label--type-inline'>Eye drops<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_24_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.4' type='checkbox'  value='Decongestants'  id='choice_4_24_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_24_4' id='label_4_24_4' class='gform-field-label gform-field-label--type-inline'>Decongestants<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_24_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.5' type='checkbox'  value='Cough syrups\/drops'  id='choice_4_24_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_24_5' id='label_4_24_5' class='gform-field-label gform-field-label--type-inline'>Cough syrups\/drops<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_24_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.6' type='checkbox'  value='Nose sprays'  id='choice_4_24_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_24_6' id='label_4_24_6' class='gform-field-label gform-field-label--type-inline'>Nose sprays<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_24_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.7' type='checkbox'  value='Beta-blockers'  id='choice_4_24_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_24_7' id='label_4_24_7' class='gform-field-label gform-field-label--type-inline'>Beta-blockers<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_24_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.8' type='checkbox'  value='Blood thinners'  id='choice_4_24_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_24_8' id='label_4_24_8' class='gform-field-label gform-field-label--type-inline'>Blood thinners<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_24_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.9' type='checkbox'  value='Antidepressants'  id='choice_4_24_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_24_9' id='label_4_24_9' class='gform-field-label gform-field-label--type-inline'>Antidepressants<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_24_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.11' type='checkbox'  value='Sleep medications'  id='choice_4_24_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_24_11' id='label_4_24_11' class='gform-field-label gform-field-label--type-inline'>Sleep medications<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_24_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.12' type='checkbox'  value='Antacids'  id='choice_4_24_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_24_12' id='label_4_24_12' class='gform-field-label gform-field-label--type-inline'>Antacids<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_25\" 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_4_25\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Have you had or do any of the following apply to you?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_25'><div class='gchoice gchoice_4_25_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.1' type='checkbox'  value='Asthma'  id='choice_4_25_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_25_1' id='label_4_25_1' class='gform-field-label gform-field-label--type-inline'>Asthma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_25_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.2' type='checkbox'  value='Anaphylaxis'  id='choice_4_25_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_25_2' id='label_4_25_2' class='gform-field-label gform-field-label--type-inline'>Anaphylaxis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_25_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.3' type='checkbox'  value='Beta-blockers'  id='choice_4_25_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_25_3' id='label_4_25_3' class='gform-field-label gform-field-label--type-inline'>Beta-blockers<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_25_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.4' type='checkbox'  value='Food allergy'  id='choice_4_25_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_25_4' id='label_4_25_4' class='gform-field-label gform-field-label--type-inline'>Food allergy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_25_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.5' type='checkbox'  value='Angioedema'  id='choice_4_25_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_25_5' id='label_4_25_5' class='gform-field-label gform-field-label--type-inline'>Angioedema<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_25_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.6' type='checkbox'  value='Pregnancy'  id='choice_4_25_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_25_6' id='label_4_25_6' class='gform-field-label gform-field-label--type-inline'>Pregnancy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_25_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.7' type='checkbox'  value='Hives'  id='choice_4_25_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_25_7' id='label_4_25_7' class='gform-field-label gform-field-label--type-inline'>Hives<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_25_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.8' type='checkbox'  value='Dermatographism'  id='choice_4_25_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_25_8' id='label_4_25_8' class='gform-field-label gform-field-label--type-inline'>Dermatographism<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_26\" 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_4_26\" ><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_4_27' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_2' class='gform_page' data-js='page-field-id-27' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_4_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_4_28\" 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_4_28\" ><h3 class=\"pretest-heading\">Allergy Testing Patient Instructions <\/h3><\/div><div id=\"field_4_29\" 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_4_29\" ><label class='gfield_label gform-field-label' for='input_4_29'>Your appointment is on:<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_4_29' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_30\" 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_4_30\" ><p>Your doctor or provider has recommended that you be tested for allergies to determine if various pollens or other\n  airborne allergens may be contributing to your current symptoms.<\/p>\n\n<p><strong>You must stop certain medications prior to allergy skin testing.<\/strong><\/p>\n\n<p>Please <strong>DO NOT<\/strong> take any medications that contain antihistamines for 5-7 days prior to the testing. These include,\n  but are not limited to the following:<\/p>\n\n<ul>\n  <li>\n    Common antihistamines (this is not a complete list)\n    <ul>\n      <li>BENADRYL\u00ae (diphenhydramine), Claritin\u00ae (loratadine), Allegra\u00ae (fexofenadine), ZYRTEC\u00ae (cetirizine), Xyzal\u00ae (levocetirizine), Clarinex (desloratadine)<\/li>\n    <\/ul>\n  <\/li>\n  <li>\n    Over-the-counter cold and cough remedies\n    <ul>\n      <li>Dimetapp\u00ae, Robitussin, TYLENOL\u00ae Cold &#038; Sinus, Chlor-Trimeton<\/li>\n    <\/ul>\n  <\/li>\n  <li>\n    Prescription or over-the-counter sleep aids\n    <ul>\n      <li>Ambien, Lunesta, Midol PM, TYLENOL\u00ae PM, Excedrin\u00ae PM, Dramamine\u00ae<\/li>\n    <\/ul>\n  <\/li>\n  <li>\n    Nasal spray antihistamines\n    <ul>\n      <li>Patanase, Astepro\u00ae, Astelin<\/li>\n    <\/ul>\n  <\/li>\n  <li>\n    Eye drop antihistamines\n    <ul>\n      <li>Optivar, Pataday\u00ae<\/li>\n    <\/ul>\n  <\/li>\n  <li>\n    Herbal supplements, multivitamins and vitamin C\n    <ul>\n      <li>Must be stopped seven days prior to testing<\/li>\n    <\/ul>\n  <\/li>\n<\/ul>\n\n<p>Please wear a <strong>SHORT-SLEEVE SHIRT<\/strong>strong, as the allergy testing will take place on the upper and lower arms. The testing will take between 60 to 90 minutes to complete. <strong>PLEASE MAKE SURE YOU ARE 15 MINUTES EARLY.<\/strong><\/p>\n\n<p>If you are on a beta-blocker, we cannot perform testing unless a prescribing M.D. gives you another form of medication<\/p>\n\n<p><strong>Examples of beta-blockers are:<\/strong><\/p>\n\n<ul>\n  <li>Bystolic (nebivolol)<\/li>\n  <li>Coreg (carvedilol)<\/li>\n  <li>Corgard (nadolol)<\/li>\n  <li>Inderal (propranolol)<\/li>\n  <li>Levatol<\/li>\n  <li>Lopressor (metoprolol)<\/li>\n  <li>Tenormin (atenolol)<\/li>\n  <li>Zebeta (bisoprolol)<\/li>\n  <li>Timolol (eye drops for glaucoma)<\/li>\n<\/ul>\n\n<p><strong>Please note:<\/strong> if you have not received a call from the allergy department within five business days, please call (843) 449-6449 option 7.<\/p><\/div><div id=\"field_4_31\" 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_4_31\" ><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><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_4' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' value='Previous'  \/>  \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_4' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_4' id='gform_theme_4' value='gravity-theme' \/>\n            <input 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