{"id":187,"date":"2023-11-06T09:20:12","date_gmt":"2023-11-06T09:20:12","guid":{"rendered":"https:\/\/demo-websitedesigns.com\/heather\/v1\/?page_id=187"},"modified":"2024-05-08T09:52:47","modified_gmt":"2024-05-08T09:52:47","slug":"gravity-form","status":"publish","type":"page","link":"https:\/\/demo-websitedesigns.com\/heather\/v1\/gravity-form\/","title":{"rendered":"Gravity Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"187\" class=\"elementor elementor-187\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-266b9412 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"266b9412\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element 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gfield_visibility_visible\"  data-js-reload=\"field_1_1\" ><h2>Personal Information<\/h2><\/div><fieldset id=\"field_1_3\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-third gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_3\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_1_3'>\n                            \n                            <span id='input_1_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_1_3_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_3_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_1_4\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_4\" ><label class='gfield_label gform-field-label' for='input_1_4'>Phone (Day)<\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_1_4' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_5\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_5\" ><label class='gfield_label gform-field-label' for='input_1_5'>Phone (Evening)<\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_1_5' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_6\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_6\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street ginput_container_address gform-grid-row' id='input_1_6' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_6_1_container' >\n                                        <input type='text' name='input_6.1' id='input_1_6_1' value=''    aria-required='true'    \/>\n                                        <label for='input_1_6_1' id='input_1_6_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><input type='hidden' class='gform_hidden' name='input_6.4' id='input_1_6_4' value=''\/><input type='hidden' class='gform_hidden' name='input_6.6' id='input_1_6_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_1_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_7\" ><label class='gfield_label gform-field-label' for='input_1_7'>City\/State\/Zip<\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_1_7' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_17\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_17\" ><label class='gfield_label gform-field-label' for='input_1_17'>Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_17' id='input_1_17' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_17_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_17_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_17' class='gform_hidden' value='https:\/\/demo-websitedesigns.com\/heather\/v1\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_9\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_9\" ><label class='gfield_label gform-field-label' for='input_1_9'>Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_1_9' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_10\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_10\" ><label class='gfield_label gform-field-label' for='input_1_10'>Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_1_10' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_11\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_11\" ><label class='gfield_label gform-field-label' for='input_1_11'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_11' id='input_1_11' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_12\" ><label class='gfield_label gform-field-label' for='input_1_12'>Primary Physician<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_1_12' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_13\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_13\" ><label class='gfield_label gform-field-label' for='input_1_13'>Emergency Contact<\/label><div class='ginput_container ginput_container_phone'><input name='input_13' id='input_1_13' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_14\" ><label class='gfield_label gform-field-label' for='input_1_14'>Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_1_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_15\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_15\" ><label class='gfield_label gform-field-label' for='input_1_15'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_15' id='input_1_15' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_16\" 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_1_16\" ><label class='gfield_label gform-field-label' for='input_1_16'>How did you hear about us?<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_1_16' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_18\" 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_1_18\" ><h2>Medical Information<\/h2><\/div><fieldset id=\"field_1_19\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_19\" ><legend class='gfield_label gform-field-label' >Are you taking any medications?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_19'>\n\t\t\t<div class='gchoice gchoice_1_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Yes'  id='choice_1_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_19_0' id='label_1_19_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='No' checked='checked' id='choice_1_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_19_1' id='label_1_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_20\" 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_1_20\" ><label class='gfield_label gform-field-label' for='input_1_20'>If yes, please list name and use:<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_1_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_21\" ><legend class='gfield_label gform-field-label' >Are you currently pregnant?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_21'>\n\t\t\t<div class='gchoice gchoice_1_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Yes'  id='choice_1_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_21_0' id='label_1_21_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='No' checked='checked' id='choice_1_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_21_1' id='label_1_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_22\" 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_1_22\" ><label class='gfield_label gform-field-label' for='input_1_22'>If yes, how far along?<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_1_22' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_23\" 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_1_23\" ><label class='gfield_label gform-field-label' for='input_1_23'>Any high risk factors?<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_1_23' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_24\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_24\" ><legend class='gfield_label gform-field-label' >Do you suffer from chronic pain?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_24'>\n\t\t\t<div class='gchoice gchoice_1_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Yes'  id='choice_1_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_24_0' id='label_1_24_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='No' checked='checked' id='choice_1_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_24_1' id='label_1_24_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_25\" 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_1_25\" ><label class='gfield_label gform-field-label' for='input_1_25'>If yes, please explain<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_1_25' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_26\" 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_1_26\" ><label class='gfield_label gform-field-label' for='input_1_26'>What makes it better?<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_1_26' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_27\" 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_1_27\" ><h2>Grief Information<\/h2><\/div><div id=\"field_1_28\" 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_1_28\" ><label class='gfield_label gform-field-label' for='input_1_28'>When did the loss occur?<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_1_28' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_31\" 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_1_31\" ><label class='gfield_label gform-field-label' for='input_1_31'>Where do you carry your stress?<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_1_31' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_30\" ><legend class='gfield_label gform-field-label' >Please indicate any of the following  that apply to you.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_30'>\n\t\t\t<div class='gchoice gchoice_1_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Headaches\/Migraines'  id='choice_1_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_30_0' id='label_1_30_0' class='gform-field-label gform-field-label--type-inline'>Headaches\/Migraines<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Arthritis'  id='choice_1_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_30_1' id='label_1_30_1' class='gform-field-label gform-field-label--type-inline'>Arthritis<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_30_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Diabetes'  id='choice_1_30_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_30_2' id='label_1_30_2' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_30_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Joint Replacement(s)'  id='choice_1_30_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_30_3' id='label_1_30_3' class='gform-field-label gform-field-label--type-inline'>Joint Replacement(s)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_30_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='High\/Low Blood Pressure'  id='choice_1_30_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_30_4' id='label_1_30_4' class='gform-field-label gform-field-label--type-inline'>High\/Low Blood Pressure<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_30_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Neuropathy'  id='choice_1_30_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_30_5' id='label_1_30_5' class='gform-field-label gform-field-label--type-inline'>Neuropathy<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_30_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Fibromyalgia'  id='choice_1_30_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_30_6' id='label_1_30_6' class='gform-field-label gform-field-label--type-inline'>Fibromyalgia<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_30_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Stroke'  id='choice_1_30_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_30_7' id='label_1_30_7' class='gform-field-label gform-field-label--type-inline'>Stroke<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_30_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Heart Attack'  id='choice_1_30_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_30_8' id='label_1_30_8' class='gform-field-label gform-field-label--type-inline'>Heart Attack<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_30_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Kidney Dysfunction'  id='choice_1_30_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_30_9' id='label_1_30_9' class='gform-field-label gform-field-label--type-inline'>Kidney Dysfunction<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_30_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Blood Clots'  id='choice_1_30_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_30_10' id='label_1_30_10' class='gform-field-label gform-field-label--type-inline'>Blood Clots<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_30_11'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='IG Issues'  id='choice_1_30_11' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_30_11' id='label_1_30_11' class='gform-field-label gform-field-label--type-inline'>IG Issues<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_30_12'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Sprains or Strains'  id='choice_1_30_12' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_30_12' id='label_1_30_12' class='gform-field-label gform-field-label--type-inline'>Sprains or Strains<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_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_1_29\" ><label class='gfield_label gform-field-label' for='input_1_29'>Explain any conditions you have marked above:<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_1_29' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_32\" 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_1_32\" ><h2>Massage Information<\/h2>\n<\/div><fieldset id=\"field_1_33\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_33\" ><legend class='gfield_label gform-field-label' >Have you had a professional massage before?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_33'>\n\t\t\t<div class='gchoice gchoice_1_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Yes'  id='choice_1_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_33_0' id='label_1_33_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='No'  id='choice_1_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_33_1' id='label_1_33_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_34\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_34\" ><legend class='gfield_label gform-field-label' >What type of massage are you seeking?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_34'>\n\t\t\t<div class='gchoice gchoice_1_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Relax &amp; Rest' checked='checked' id='choice_1_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_34_0' id='label_1_34_0' class='gform-field-label gform-field-label--type-inline'>Relax &amp; Rest<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Grief Massage'  id='choice_1_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_34_1' id='label_1_34_1' class='gform-field-label gform-field-label--type-inline'>Grief Massage<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_34_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Others'  id='choice_1_34_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_34_2' id='label_1_34_2' class='gform-field-label gform-field-label--type-inline'>Others<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_35\" 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_1_35\" ><label class='gfield_label gform-field-label' for='input_1_35'>Other<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_1_35' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_36\" ><legend class='gfield_label gform-field-label' >What pressure do you prefer?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_36'>\n\t\t\t<div class='gchoice gchoice_1_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Light'  id='choice_1_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_36_0' id='label_1_36_0' class='gform-field-label gform-field-label--type-inline'>Light<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Medium'  id='choice_1_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_36_1' id='label_1_36_1' class='gform-field-label gform-field-label--type-inline'>Medium<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_36_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Deep'  id='choice_1_36_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_36_2' id='label_1_36_2' class='gform-field-label gform-field-label--type-inline'>Deep<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_37\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_37\" ><legend class='gfield_label gform-field-label' >Do you have any allergies or sensitivities?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_37'>\n\t\t\t<div class='gchoice gchoice_1_37_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Yes'  id='choice_1_37_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_37_0' id='label_1_37_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_37_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='No' checked='checked' id='choice_1_37_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_37_1' id='label_1_37_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_38\" 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_1_38\" ><label class='gfield_label gform-field-label' for='input_1_38'>If Yes, please explain<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_1_38' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_40\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_40\" ><legend class='gfield_label gform-field-label' >Are there any areas (feet, face, abdomen, etc.) you do not want massaged?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_40'>\n\t\t\t<div class='gchoice gchoice_1_40_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Yes'  id='choice_1_40_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_40_0' id='label_1_40_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_40_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='No' checked='checked' id='choice_1_40_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_40_1' id='label_1_40_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_41\" 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_1_41\" ><label class='gfield_label gform-field-label' for='input_1_41'>If Yes, please explain<\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_1_41' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_42\" 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_1_42\" ><label class='gfield_label gform-field-label' for='input_1_42'>What are your goals for this treatment session?<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_1_42' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_43\" 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_1_43\" ><img decoding=\"async\" src=\"https:\/\/demo-websitedesigns.com\/heather\/v1\/wp-content\/uploads\/2024\/05\/15-3.png\"><\/div><fieldset id=\"field_1_44\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_44\" ><legend class='gfield_label gform-field-label' >Please circle any areas of discomfort<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_44'>\n\t\t\t<div class='gchoice gchoice_1_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='1'  id='choice_1_44_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_44_0' id='label_1_44_0' class='gform-field-label gform-field-label--type-inline'>1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='2'  id='choice_1_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_44_1' id='label_1_44_1' class='gform-field-label gform-field-label--type-inline'>2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_44_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='3'  id='choice_1_44_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_44_2' id='label_1_44_2' class='gform-field-label gform-field-label--type-inline'>3<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_44_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='4'  id='choice_1_44_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_44_3' id='label_1_44_3' class='gform-field-label gform-field-label--type-inline'>4<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_45\" 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_1_45\" >By signing below you agree to the following:<br>\n\nI have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.<\/div><div id=\"field_1_46\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_46\" ><label class='gfield_label gform-field-label' for='input_1_46'>Client Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_1_46_Container' class='gfield_signature_container ginput_container' style='height:180px; width:400px; ' ><input type='hidden' class='gform_hidden' name='input_1_46_valid' id='input_1_46_valid' \/><canvas id='input_1_46' width='400' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_1_47\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_47\" ><label class='gfield_label gform-field-label' for='input_1_47'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_47' id='input_1_47' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_47_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_47_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_47' class='gform_hidden' value='https:\/\/demo-websitedesigns.com\/heather\/v1\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_48\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_48\" ><label class='gfield_label gform-field-label' for='input_1_48'>Therapist Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_1_48_Container' class='gfield_signature_container ginput_container' style='height:180px; width:400px; ' ><input type='hidden' class='gform_hidden' name='input_1_48_valid' id='input_1_48_valid' \/><canvas id='input_1_48' width='400' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_1_49\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_49\" ><label class='gfield_label gform-field-label' for='input_1_49'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_49' id='input_1_49' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_49_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_49_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_49' class='gform_hidden' value='https:\/\/demo-websitedesigns.com\/heather\/v1\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><\/div><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  jQuery(\"#gform_1\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' 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