{"id":419,"date":"2017-04-11T13:19:23","date_gmt":"2017-04-11T17:19:23","guid":{"rendered":"http:\/\/melvilledental.com\/?page_id=419\/"},"modified":"2017-07-20T10:09:04","modified_gmt":"2017-07-20T14:09:04","slug":"questionnaire-dinscription-confidentiel","status":"publish","type":"page","link":"https:\/\/melvilledental.com\/fr\/questionnaire-dinscription-confidentiel\/","title":{"rendered":"Questionnaire d&rsquo;inscription confidentiel"},"content":{"rendered":"<div style=\"display:none\" class=\"fm-form-container fm-theme0\"><div id=\"fm-pages14\" class=\"fm-pages wdform_page_navigation \" show_title=\"true\" show_numbers=\"true\" type=\"percentage\"><\/div><form name=\"form14\" action=\"\/fr\/wp-json\/wp\/v2\/pages\/419\" method=\"post\" id=\"form14\" class=\"fm-form form14  \" enctype=\"multipart\/form-data\"><input type=\"hidden\" id=\"counter14\" value=\"189\" name=\"counter14\" \/><input type=\"hidden\" id=\"Itemid14\" value=\"\" name=\"Itemid14\" \/><input type=\"text\" class=\"fm-hide\" id=\"fm_bot_validation14\" value=\"\" name=\"fm_bot_validation14\" \/><input type=\"text\" class=\"fm-hide\" id=\"fm_empty_field_validation14\" value=\"\" name=\"fm_empty_field_validation14\" data-value=\"4ec52002dcce538d7655ecce20b6a124\" \/><input type=\"hidden\" id=\"fm_form_nonce14\" name=\"fm_form_nonce14\" value=\"40063ce0d5\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/fr\/wp-json\/wp\/v2\/pages\/419\" \/><div class=\"fm-header-bg\"><div class=\"fm-header \"><div class=\"fm-header-text\">          <div class=\"fm-header-title\">            CONFIDENTIAL MEDICAL-DENTAL QUESTIONNAIRE          <\/div>          <div class=\"fm-header-description\">            <div data-canvas-width=\"1008.4297897058832\">A patient\u2019s dental file contains information on the care provided to the patient. It is protected by law and professional secrecy and kept at the dental office, where only the dentist and his or her staff have access to it. Patients are also entitled to access their file and make corrections.<\/div>          <\/div>        <\/div><\/div><\/div><div class=\"wdform-page-and-images\" style=\"display: table; border-width: 0px; border-top-style: solid; border-top-color: black;\"><div id=\"14form_view1\" class=\"wdform_page\" page_title=\"Patient Informations\" next_title=\"Next\" next_type=\"text\" next_class=\"wdform-page-button\" next_checkable=\"false\" previous_title=\"Previous\" previous_type=\"text\" previous_class=\"wdform-page-button\" previous_checkable=\"false\"><div class=\"wdform_section\"><div class=\"wdform_column \" style=\"border: none;\"><div wdid=\"6\" class=\"wdform_row \"><div type=\"type_editor\" class=\"wdform-field\"><p>Renseignements personnels<\/p><\/div><\/div><div wdid=\"7\" class=\"wdform_row \"><div type=\"type_name\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-row\" style=\"max-width: 100px;\">    <label  for=\"wdform_7_element_first14\" class=\"wdform-label\">Nom:<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-width-70\" style=\"max-width: 100px;\"><div class=\"wd-flex wd-flex-column wd-width-50\"><input type=\"text\" class=\"wd-width-100\" id=\"wdform_7_element_first14\" name=\"wdform_7_element_first14\" value=\"\" title=\"\" placeholder=\"\"  \/><label class=\"mini_label\" for=\"wdform_7_element_first14\">Pr\u00e9nom<\/label><\/div><div class=\"wd-flex wd-flex-column wd-name-separator\"><\/div><div class=\"wd-flex wd-flex-column wd-width-50\"><input type=\"text\" class=\"wd-width-100\" id=\"wdform_7_element_last14\" name=\"wdform_7_element_last14\" value=\"\" title=\"\" placeholder=\"\"  \/><label class=\"mini_label\" for=\"wdform_7_element_last14\">Nom<\/label><\/div><\/div><\/div><\/div><div wdid=\"8\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 100px;\">    <label  class=\"wdform-label\">Sexe:<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_8_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_8_element140\" name=\"wdform_8_element14\" value=\"F\" onclick=\"set_default(&quot;wdform_8&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_8_element140\"><span><\/span>F<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_8_element141\" name=\"wdform_8_element14\" value=\"H\" onclick=\"set_default(&quot;wdform_8&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_8_element141\"><span><\/span>H<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_8_element142\" name=\"wdform_8_element14\" value=\"Autre\" onclick=\"set_default(&quot;wdform_8&quot;,&quot;2&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_8_element142\"><span><\/span>Autre<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"175\" class=\"wdform_row \"><div type=\"type_date_fields\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30 wdform_date_fields wd-flex-row\" style=\"max-width: 100px;\">    <label  for=\"wdform_175_day14\" class=\"wdform-label\">Date de naissance :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex wdform_date_fields wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row wd-width-100 wd-align-items\"><div class=\"wd-flex wd-flex-column\"><select id=\"wdform_175_day14\" name=\"wdform_175_day14\" style=\"width: 60px;\" ><option value=\"\"><\/option><option value=\"01\" >01<\/option><option value=\"02\" >02<\/option><option value=\"03\" >03<\/option><option value=\"04\" >04<\/option><option value=\"05\" >05<\/option><option value=\"06\" >06<\/option><option value=\"07\" >07<\/option><option value=\"08\" >08<\/option><option value=\"09\" >09<\/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><label for=\"wdform_175_day14\" class=\"mini_label\">Jour<\/label><\/div><span class=\"wdform_separator\">&nbsp;\/&nbsp;<\/span><div class=\"wd-flex wd-flex-column\"><select id=\"wdform_175_month14\" name=\"wdform_175_month14\" style=\"width: 100px;\" ><option value=\"\"><\/option><option value=\"01\"   >Janvier<\/option><option value=\"02\" >f\u00e9vrier<\/option><option value=\"03\" >mars<\/option><option value=\"04\"  >Avril<\/option><option value=\"05\"  >Mai<\/option><option value=\"06\"  >juin<\/option><option value=\"07\"  >Juillet<\/option><option value=\"08\"  >ao\u00fbt<\/option><option value=\"09\"  >Septembre<\/option><option value=\"10\"  >octobre<\/option><option value=\"11\" >novembre<\/option><option value=\"12\"  >D\u00e9cembre<\/option><\/select><label for=\"wdform_175_month14\" class=\"mini_label\">Mois<\/label><\/div><span class=\"wdform_separator\">&nbsp;\/&nbsp;<\/span><div class=\"wd-flex wd-flex-column\"><select id=\"wdform_175_year14\" name=\"wdform_175_year14\"  from=\"1901\" to=\"2017\" style=\"width: 80px;\" ><option value=\"\"><\/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><option value=\"1919\" >1919<\/option><option value=\"1918\" >1918<\/option><option value=\"1917\" >1917<\/option><option value=\"1916\" >1916<\/option><option value=\"1915\" >1915<\/option><option value=\"1914\" >1914<\/option><option value=\"1913\" >1913<\/option><option value=\"1912\" >1912<\/option><option value=\"1911\" >1911<\/option><option value=\"1910\" >1910<\/option><option value=\"1909\" >1909<\/option><option value=\"1908\" >1908<\/option><option value=\"1907\" >1907<\/option><option value=\"1906\" >1906<\/option><option value=\"1905\" >1905<\/option><option value=\"1904\" >1904<\/option><option value=\"1903\" >1903<\/option><option value=\"1902\" >1902<\/option><option value=\"1901\" >1901<\/option><\/select><label for=\"wdform_175_year14\" class=\"mini_label\">Ann\u00e9e<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"10\" class=\"wdform_row \"><div type=\"type_text\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-row wd-align-items-center\" style=\"max-width: 100px;\">    <label  for=\"wdform_10_element14\" class=\"wdform-label\">Num. d'ass maladie :<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-align-items-center wd-width-70\" style=\"max-width: 200px;\"><input type=\"text\"                           class=\"wd-width-100\"                           id=\"wdform_10_element14\"                           name=\"wdform_10_element14\"                           value=\"\"                           title=\"\"                           placeholder=\"\"                                                       \/><\/div><\/div><\/div><div wdid=\"11\" class=\"wdform_row \"><div type=\"type_date_fields\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30 wdform_date_fields wd-flex-row\" style=\"max-width: 100px;\">    <label  for=\"wdform_11_day14\" class=\"wdform-label\"> Expiration :<\/label><\/div><div class=\"wdform-element-section wd-flex wdform_date_fields wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row wd-width-100 wd-align-items\"><div class=\"wd-flex wd-flex-column\"><select id=\"wdform_11_day14\" name=\"wdform_11_day14\" style=\"width: 60px;\" ><option value=\"\"><\/option><option value=\"01\" >01<\/option><option value=\"02\" >02<\/option><option value=\"03\" >03<\/option><option value=\"04\" >04<\/option><option value=\"05\" >05<\/option><option value=\"06\" >06<\/option><option value=\"07\" >07<\/option><option value=\"08\" >08<\/option><option value=\"09\" >09<\/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><label for=\"wdform_11_day14\" class=\"mini_label\">Jour<\/label><\/div><span class=\"wdform_separator\">&nbsp;\/&nbsp;<\/span><div class=\"wd-flex wd-flex-column\"><select id=\"wdform_11_month14\" name=\"wdform_11_month14\" style=\"width: 100px;\" ><option value=\"\"><\/option><option value=\"01\"   >Janvier<\/option><option value=\"02\" >f\u00e9vrier<\/option><option value=\"03\" >mars<\/option><option value=\"04\"  >Avril<\/option><option value=\"05\"  >Mai<\/option><option value=\"06\"  >juin<\/option><option value=\"07\"  >Juillet<\/option><option value=\"08\"  >ao\u00fbt<\/option><option value=\"09\"  >Septembre<\/option><option value=\"10\"  >octobre<\/option><option value=\"11\" >novembre<\/option><option value=\"12\"  >D\u00e9cembre<\/option><\/select><label for=\"wdform_11_month14\" class=\"mini_label\">Mois<\/label><\/div><span class=\"wdform_separator\">&nbsp;\/&nbsp;<\/span><div class=\"wd-flex wd-flex-column\"><select id=\"wdform_11_year14\" name=\"wdform_11_year14\"  from=\"1901\" to=\"2028\" style=\"width: 80px;\" ><option value=\"\"><\/option><option value=\"2028\" >2028<\/option><option value=\"2027\" >2027<\/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><option value=\"1919\" >1919<\/option><option value=\"1918\" >1918<\/option><option value=\"1917\" >1917<\/option><option value=\"1916\" >1916<\/option><option value=\"1915\" >1915<\/option><option value=\"1914\" >1914<\/option><option value=\"1913\" >1913<\/option><option value=\"1912\" >1912<\/option><option value=\"1911\" >1911<\/option><option value=\"1910\" >1910<\/option><option value=\"1909\" >1909<\/option><option value=\"1908\" >1908<\/option><option value=\"1907\" >1907<\/option><option value=\"1906\" >1906<\/option><option value=\"1905\" >1905<\/option><option value=\"1904\" >1904<\/option><option value=\"1903\" >1903<\/option><option value=\"1902\" >1902<\/option><option value=\"1901\" >1901<\/option><\/select><label for=\"wdform_11_year14\" class=\"mini_label\">Ann\u00e9e<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"12\" class=\"wdform_row \"><div type=\"type_address\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30 wdform_address wd-flex-column\" style=\"max-width: 100px;\">    <label  for=\"wdform_12_street114\" class=\"wdform-label\">Adresse:<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex wdform_address wd-flex-column wd-width-70\" style=\"max-width: 300px;\"><span class=\"wd-width-100 wd-address\">                <input class=\"wd-width-100\" type=\"text\" id=\"wdform_12_street114\" name=\"wdform_12_street114\" value=\"\"  \/>                <label for=\"wdform_12_street114\" class=\"mini_label\">rue<\/label><\/span><span class=\"wd-width-100 wd-flex wd-flex-row wd-flex-wrap wd-justify-content\"><span class=\"wd-width-49 wd-address\">                <input class=\"wd-width-100\" type=\"text\" id=\"wdform_12_city14\" name=\"wdform_14_city14\" value=\"\"  \/>                <label for=\"wdform_12_city14\" class=\"mini_label\">Ville<\/label><\/span><span class=\"wd-width-49 wd-address\">                <input class=\"wd-width-100\" type=\"text\" id=\"wdform_12_state14\" name=\"wdform_15_state14\" value=\"\"  \/>                <label for=\"wdform_12_state14\" class=\"mini_label\">Province<\/label><\/span><span class=\"wd-width-49 wd-address\">              <input class=\"wd-width-100\" type=\"text\" id=\"wdform_12_postal14\" name=\"wdform_16_postal14\" value=\"\"  \/>              <label for=\"wdform_12_postal14\" class=\"mini_label\">Code postal<\/label><\/span><span class=\"wd-width-49 wd-address\">              <select class=\"wd-width-100\"                      type=\"text\"                      id=\"wdform_12_country14\"                      name=\"wdform_17_country14\"                                            ><option value=\"\" selected=\"selected\"><\/option><option value=\"Afghanistan\" >Afghanistan<\/option><option value=\"Albania\" >Albania<\/option><option value=\"Algeria\" >Algeria<\/option><option value=\"Andorra\" >Andorra<\/option><option value=\"Angola\" >Angola<\/option><option value=\"Antigua and Barbuda\" >Antigua and Barbuda<\/option><option value=\"Argentina\" >Argentina<\/option><option value=\"Armenia\" >Armenia<\/option><option value=\"Australia\" >Australia<\/option><option value=\"Austria\" >Austria<\/option><option value=\"Azerbaijan\" >Azerbaijan<\/option><option value=\"Bahamas\" >Bahamas<\/option><option value=\"Bahrain\" >Bahrain<\/option><option value=\"Bangladesh\" >Bangladesh<\/option><option value=\"Barbados\" >Barbados<\/option><option value=\"Belarus\" >Belarus<\/option><option value=\"Belgium\" >Belgium<\/option><option value=\"Belize\" >Belize<\/option><option value=\"Benin\" >Benin<\/option><option value=\"Bhutan\" >Bhutan<\/option><option value=\"Bolivia\" >Bolivia<\/option><option value=\"Bosnia and Herzegovina\" >Bosnia and Herzegovina<\/option><option value=\"Botswana\" >Botswana<\/option><option value=\"Brazil\" >Brazil<\/option><option value=\"Brunei\" >Brunei<\/option><option value=\"Bulgaria\" >Bulgaria<\/option><option value=\"Burkina\" >Burkina Faso<\/option><option value=\"Burundi\" >Burundi<\/option><option value=\"Cambodia\" >Cambodia<\/option><option value=\"Cameroon\" >Cameroon<\/option><option value=\"Canada\" >Canada<\/option><option value=\"Cape Verde\" >Cape Verde<\/option><option value=\"Central African Republic\" >Central African Republic<\/option><option value=\"Chad\" >Chad<\/option><option value=\"Chile\" >Chile<\/option><option value=\"China\" >China<\/option><option value=\"Colombia\" >Colombia<\/option><option value=\"Comoros\" >Comoros<\/option><option value=\"Congo\" >Congo<\/option><option value=\"Congo (Brazzaville)\" >Congo (Brazzaville)<\/option><option value=\"Costa Rica\" >Costa Rica<\/option><option value=\"Cote d'Ivoire\" >Cote d'Ivoire<\/option><option value=\"Croatia\" >Croatia<\/option><option value=\"Cuba\" >Cuba<\/option><option value=\"Curacao\" >Curacao<\/option><option value=\"Cyprus\" >Cyprus<\/option><option value=\"Czech Republic\" >Czech Republic<\/option><option value=\"Denmark\" >Denmark<\/option><option value=\"Djibouti\" >Djibouti<\/option><option value=\"Dominica\" >Dominica<\/option><option value=\"Dominican Republic\" >Dominican Republic<\/option><option value=\"East Timor (Timor Timur\" >East Timor (Timor Timur)<\/option><option value=\"Ecuador\" >Ecuador<\/option><option value=\"Egypt\" >Egypt<\/option><option value=\"El Salvador\" >El Salvador<\/option><option value=\"Equatorial\" >Equatorial Guinea<\/option><option value=\"Eritrea\" >Eritrea<\/option><option value=\"Estonia\" >Estonia<\/option><option value=\"Eswatini\" >Eswatini<\/option><option value=\"Ethiopia\" >Ethiopia<\/option><option value=\"Fiji\" >Fiji<\/option><option value=\"Finland\" >Finland<\/option><option value=\"France\" >France<\/option><option value=\"Gabon\" >Gabon<\/option><option value=\"Gambia, The\" >Gambia, The<\/option><option value=\"Georgia\" >Georgia<\/option><option value=\"Germany\" >Germany<\/option><option value=\"Ghana\" >Ghana<\/option><option value=\"Greece\" >Greece<\/option><option value=\"Grenada\" >Grenada<\/option><option value=\"Guatemala\" >Guatemala<\/option><option value=\"Guinea\" >Guinea<\/option><option value=\"Guinea-Bissau\" >Guinea-Bissau<\/option><option value=\"Guyana\" >Guyana<\/option><option value=\"Haiti\" >Haiti<\/option><option value=\"Honduras\" >Honduras<\/option><option value=\"Hong Kong\" >Hong Kong<\/option><option value=\"Hungary\" >Hungary<\/option><option value=\"Iceland\" >Iceland<\/option><option value=\"India\" >India<\/option><option value=\"Indonesia\" >Indonesia<\/option><option value=\"Iran\" >Iran<\/option><option value=\"Iraq\" >Iraq<\/option><option value=\"Ireland\" >Ireland<\/option><option value=\"Israel\" >Israel<\/option><option value=\"Italy\" >Italy<\/option><option value=\"Jamaica\" >Jamaica<\/option><option value=\"Japan\" >Japan<\/option><option value=\"Jordan\" >Jordan<\/option><option value=\"Kazakhstan\" >Kazakhstan<\/option><option value=\"Kenya\" >Kenya<\/option><option value=\"Kiribati\" >Kiribati<\/option><option value=\"Korea, North\" >Korea, North<\/option><option value=\"Korea, South\" >Korea, South<\/option><option value=\"Kuwait\" >Kuwait<\/option><option value=\"Kyrgyzstan\" >Kyrgyzstan<\/option><option value=\"Laos\" >Laos<\/option><option value=\"Latvia\" >Latvia<\/option><option value=\"Lebanon\" >Lebanon<\/option><option value=\"Lesotho\" >Lesotho<\/option><option value=\"Liberia\" >Liberia<\/option><option value=\"Libya\" >Libya<\/option><option value=\"Liechtenstein\" >Liechtenstein<\/option><option value=\"Lithuania\" >Lithuania<\/option><option value=\"Luxembourg\" >Luxembourg<\/option><option value=\"Madagascar\" >Madagascar<\/option><option value=\"Malawi\" >Malawi<\/option><option value=\"Malaysia\" >Malaysia<\/option><option value=\"Maldives\" >Maldives<\/option><option value=\"Mali\" >Mali<\/option><option value=\"Malta\" >Malta<\/option><option value=\"Marshall Islands\" >Marshall Islands<\/option><option value=\"Mauritania\" >Mauritania<\/option><option value=\"Mauritius\" >Mauritius<\/option><option value=\"Mexico\" >Mexico<\/option><option value=\"Micronesia\" >Micronesia<\/option><option value=\"Moldova\" >Moldova<\/option><option value=\"Monaco\" >Monaco<\/option><option value=\"Mongolia\" >Mongolia<\/option><option value=\"Montenegro\" >Montenegro<\/option><option value=\"Morocco\" >Morocco<\/option><option value=\"Mozambique\" >Mozambique<\/option><option value=\"Myanmar\" >Myanmar<\/option><option value=\"Namibia\" >Namibia<\/option><option value=\"Nauru\" >Nauru<\/option><option value=\"Nepal\" >Nepal<\/option><option value=\"Netherlands\" >Netherlands<\/option><option value=\"New Zealand\" >New Zealand<\/option><option value=\"Nicaragua\" >Nicaragua<\/option><option value=\"Niger\" >Niger<\/option><option value=\"Nigeria\" >Nigeria<\/option><option value=\"North Macedonia\" >North Macedonia<\/option><option value=\"Norway\" >Norway<\/option><option value=\"Oman\" >Oman<\/option><option value=\"Pakistan\" >Pakistan<\/option><option value=\"Palau\" >Palau<\/option><option value=\"Palestine\" >Palestine<\/option><option value=\"Panama\" >Panama<\/option><option value=\"Papua New Guinea\" >Papua New Guinea<\/option><option value=\"Paraguay\" >Paraguay<\/option><option value=\"Peru\" >Peru<\/option><option value=\"Philippines\" >Philippines<\/option><option value=\"Poland\" >Poland<\/option><option value=\"Portugal\" >Portugal<\/option><option value=\"Puerto Rico\" >Puerto Rico<\/option><option value=\"Qatar\" >Qatar<\/option><option value=\"Romania\" >Romania<\/option><option value=\"Russia\" >Russia<\/option><option value=\"Rwanda\" >Rwanda<\/option><option value=\"Saint Kitts and Nevis\" >Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\" >Saint Lucia<\/option><option value=\"Saint Vincent\" >Saint Vincent<\/option><option value=\"Samoa\" >Samoa<\/option><option value=\"San Marino\" >San Marino<\/option><option value=\"Sao Tome and Principe\" >Sao Tome and Principe<\/option><option value=\"Saudi Arabia\" >Saudi Arabia<\/option><option value=\"Senegal\" >Senegal<\/option><option value=\"Serbia\" >Serbia<\/option><option value=\"Seychelles\" >Seychelles<\/option><option value=\"Sierra Leone\" >Sierra Leone<\/option><option value=\"Singapore\" >Singapore<\/option><option value=\"Slovakia\" >Slovakia<\/option><option value=\"Slovenia\" >Slovenia<\/option><option value=\"Solomon Islands\" >Solomon Islands<\/option><option value=\"Somalia\" >Somalia<\/option><option value=\"South Africa\" >South Africa<\/option><option value=\"Spain\" >Spain<\/option><option value=\"Sri Lanka\" >Sri Lanka<\/option><option value=\"Sudan\" >Sudan<\/option><option value=\"Suriname\" >Suriname<\/option><option value=\"Sweden\" >Sweden<\/option><option value=\"Switzerland\" >Switzerland<\/option><option value=\"Syria\" >Syria<\/option><option value=\"Taiwan\" >Taiwan<\/option><option value=\"Tajikistan\" >Tajikistan<\/option><option value=\"Tanzania\" >Tanzania<\/option><option value=\"Thailand\" >Thailand<\/option><option value=\"Togo\" >Togo<\/option><option value=\"Tonga\" >Tonga<\/option><option value=\"Trinidad and Tobago\" >Trinidad and Tobago<\/option><option value=\"Tunisia\" >Tunisia<\/option><option value=\"Turkey\" >Turkey<\/option><option value=\"Turkmenistan\" >Turkmenistan<\/option><option value=\"Tuvalu\" >Tuvalu<\/option><option value=\"Uganda\" >Uganda<\/option><option value=\"Ukraine\" >Ukraine<\/option><option value=\"United Arab Emirates\" >United Arab Emirates<\/option><option value=\"United Kingdom\" >United Kingdom<\/option><option value=\"United States\" >United States<\/option><option value=\"Uruguay\" >Uruguay<\/option><option value=\"Uzbekistan\" >Uzbekistan<\/option><option value=\"Vanuatu\" >Vanuatu<\/option><option value=\"Vatican City\" >Vatican City<\/option><option value=\"Venezuela\" >Venezuela<\/option><option value=\"Vietnam\" >Vietnam<\/option><option value=\"Wales\" >Wales<\/option><option value=\"Yemen\" >Yemen<\/option><option value=\"Zambia\" >Zambia<\/option><option value=\"Zimbabwe\" >Zimbabwe<\/option><\/select>              <label for=\"wdform_12_country14\" class=\"mini_label\">Pays<\/label><\/span><\/span><\/div><\/div><\/div><div wdid=\"18\" class=\"wdform_row \"><div type=\"type_editor\" class=\"wdform-field\"><p><strong>Coordonn\u00e9es<\/strong><\/p><\/div><\/div><div wdid=\"19\" class=\"wdform_row \"><div type=\"type_phone\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-row\" style=\"max-width: 100px;\">    <label  for=\"wdform_19_element_first14\" class=\"wdform-label\">T\u00e9l. domicile :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-width-70\" style=\"max-width: 135px;\"><div class=\"wd-flex wd-flex-column wd-width-20\">                <input type=\"text\" class=\"wd-phone-first\" id=\"wdform_19_element_first14\" name=\"wdform_19_element_first14\" value=\"\" title=\"\" placeholder=\"\" >                <label for=\"wdform_19_element_first14\" class=\"mini_label wd-flex-column\">Indicatif<\/label>              <\/div>              <div>                <div class=\"wd-flex wd-flex-column \">&nbsp;-&nbsp;<\/div>              <\/div>              <div class=\"wd-flex wd-flex-column wd-width-80\">                <input type=\"text\" class=\"wd-flex-column wd-width-100\" id=\"wdform_19_element_last14\" name=\"wdform_19_element_last14\" value=\"\" title=\"\" placeholder=\"\"  \/>                <label for=\"wdform_19_element_last14\" class=\"wd-flex-column mini_label\">Num\u00e9ro<\/label>              <\/div><\/div><\/div><\/div><div wdid=\"20\" class=\"wdform_row \"><div type=\"type_phone\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-row\" style=\"max-width: 100px;\">    <label  for=\"wdform_20_element_first14\" class=\"wdform-label\">T\u00e9l. travail :<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-width-70\" style=\"max-width: 135px;\"><div class=\"wd-flex wd-flex-column wd-width-20\">                <input type=\"text\" class=\"wd-phone-first\" id=\"wdform_20_element_first14\" name=\"wdform_20_element_first14\" value=\"\" title=\"\" placeholder=\"\" >                <label for=\"wdform_20_element_first14\" class=\"mini_label wd-flex-column\">Indicatif<\/label>              <\/div>              <div>                <div class=\"wd-flex wd-flex-column \">&nbsp;-&nbsp;<\/div>              <\/div>              <div class=\"wd-flex wd-flex-column wd-width-80\">                <input type=\"text\" class=\"wd-flex-column wd-width-100\" id=\"wdform_20_element_last14\" name=\"wdform_20_element_last14\" value=\"\" title=\"\" placeholder=\"\"  \/>                <label for=\"wdform_20_element_last14\" class=\"wd-flex-column mini_label\">Num\u00e9ro<\/label>              <\/div><\/div><\/div><\/div><div wdid=\"21\" class=\"wdform_row \"><div type=\"type_phone\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-row\" style=\"max-width: 100px;\">    <label  for=\"wdform_21_element_first14\" class=\"wdform-label\">T\u00e9l. Cell. :<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-width-70\" style=\"max-width: 135px;\"><div class=\"wd-flex wd-flex-column wd-width-20\">                <input type=\"text\" class=\"wd-phone-first\" id=\"wdform_21_element_first14\" name=\"wdform_21_element_first14\" value=\"\" title=\"\" placeholder=\"\" >                <label for=\"wdform_21_element_first14\" class=\"mini_label wd-flex-column\">Indicatif<\/label>              <\/div>              <div>                <div class=\"wd-flex wd-flex-column \">&nbsp;-&nbsp;<\/div>              <\/div>              <div class=\"wd-flex wd-flex-column wd-width-80\">                <input type=\"text\" class=\"wd-flex-column wd-width-100\" id=\"wdform_21_element_last14\" name=\"wdform_21_element_last14\" value=\"\" title=\"\" placeholder=\"\"  \/>                <label for=\"wdform_21_element_last14\" class=\"wd-flex-column mini_label\">Num\u00e9ro<\/label>              <\/div><\/div><\/div><\/div><div wdid=\"22\" class=\"wdform_row \"><div type=\"type_submitter_mail\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-row\" style=\"max-width: 100px;\">    <label  for=\"wdform_22_element14\" class=\"wdform-label\">Courriel:<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-width-70\" style=\"max-width: 200px;\"><input type=\"text\" class=\"wd-width-100\" id=\"wdform_22_element14\" name=\"wdform_22_element14\" value=\"\" title=\"\" placeholder=\"\"   onchange=\"wd_check_email('22', '14', 'Ceci n\\'est pas une adresse e-mail valide')\" \/><\/div><\/div><\/div><div wdid=\"23\" class=\"wdform_row \"><div type=\"type_editor\" class=\"wdform-field\"><p><strong>En cas d\u2019urgence, appeler :<\/strong><\/p><\/div><\/div><div wdid=\"24\" class=\"wdform_row \"><div type=\"type_name\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-row\" style=\"max-width: 150px;\">    <label  for=\"wdform_24_element_first14\" class=\"wdform-label\">Nom d'une tierce personne :<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-width-70\" style=\"max-width: 100px;\"><div class=\"wd-flex wd-flex-column wd-width-50\"><input type=\"text\" class=\"wd-width-100\" id=\"wdform_24_element_first14\" name=\"wdform_24_element_first14\" value=\"\" title=\"\" placeholder=\"\"  \/><label class=\"mini_label\" for=\"wdform_24_element_first14\">Pr\u00e9nom<\/label><\/div><div class=\"wd-flex wd-flex-column wd-name-separator\"><\/div><div class=\"wd-flex wd-flex-column wd-width-50\"><input type=\"text\" class=\"wd-width-100\" id=\"wdform_24_element_last14\" name=\"wdform_24_element_last14\" value=\"\" title=\"\" placeholder=\"\"  \/><label class=\"mini_label\" for=\"wdform_24_element_last14\">Nom<\/label><\/div><\/div><\/div><\/div><div wdid=\"25\" class=\"wdform_row \"><div type=\"type_text\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-row wd-align-items-center\" style=\"max-width: 100px;\">    <label  for=\"wdform_25_element14\" class=\"wdform-label\">Lien avec le patient :<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-align-items-center wd-width-70\" style=\"max-width: 200px;\"><input type=\"text\"                           class=\"wd-width-100\"                           id=\"wdform_25_element14\"                           name=\"wdform_25_element14\"                           value=\"\"                           title=\"\"                           placeholder=\"\"                                                       \/><\/div><\/div><\/div><div wdid=\"26\" class=\"wdform_row \"><div type=\"type_phone\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-row\" style=\"max-width: 100px;\">    <label  for=\"wdform_26_element_first14\" class=\"wdform-label\">T\u00e9l. principal :<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-width-70\" style=\"max-width: 135px;\"><div class=\"wd-flex wd-flex-column wd-width-20\">                <input type=\"text\" class=\"wd-phone-first\" id=\"wdform_26_element_first14\" name=\"wdform_26_element_first14\" value=\"\" title=\"\" placeholder=\"\" >                <label for=\"wdform_26_element_first14\" class=\"mini_label wd-flex-column\">Indicatif<\/label>              <\/div>              <div>                <div class=\"wd-flex wd-flex-column \">&nbsp;-&nbsp;<\/div>              <\/div>              <div class=\"wd-flex wd-flex-column wd-width-80\">                <input type=\"text\" class=\"wd-flex-column wd-width-100\" id=\"wdform_26_element_last14\" name=\"wdform_26_element_last14\" value=\"\" title=\"\" placeholder=\"\"  \/>                <label for=\"wdform_26_element_last14\" class=\"wd-flex-column mini_label\">Num\u00e9ro<\/label>              <\/div><\/div><\/div><\/div><div wdid=\"27\" class=\"wdform_row \"><div type=\"type_phone\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-row\" style=\"max-width: 100px;\">    <label  for=\"wdform_27_element_first14\" class=\"wdform-label\">T\u00e9l. cell. :<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-width-70\" style=\"max-width: 135px;\"><div class=\"wd-flex wd-flex-column wd-width-20\">                <input type=\"text\" class=\"wd-phone-first\" id=\"wdform_27_element_first14\" name=\"wdform_27_element_first14\" value=\"\" title=\"\" placeholder=\"\" >                <label for=\"wdform_27_element_first14\" class=\"mini_label wd-flex-column\">Indicatif<\/label>              <\/div>              <div>                <div class=\"wd-flex wd-flex-column \">&nbsp;-&nbsp;<\/div>              <\/div>              <div class=\"wd-flex wd-flex-column wd-width-80\">                <input type=\"text\" class=\"wd-flex-column wd-width-100\" id=\"wdform_27_element_last14\" name=\"wdform_27_element_last14\" value=\"\" title=\"\" placeholder=\"\"  \/>                <label for=\"wdform_27_element_last14\" class=\"wd-flex-column mini_label\">Num\u00e9ro<\/label>              <\/div><\/div><\/div><\/div><div wdid=\"28\" class=\"wdform_row \"><div type=\"type_editor\" class=\"wdform-field\"><p><strong>Informations dentaires :<\/strong><\/p><\/div><\/div><div wdid=\"177\" class=\"wdform_row \"><div type=\"type_editor\" class=\"wdform-field\"><p>Raison de la visite aujourd'hui :<\/p><\/div><\/div><div wdid=\"176\" class=\"wdform_row \"><div type=\"type_own_select\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30 wdform_select wd-flex-row\" style=\"max-width: 100px;\">    <label  for=\"wdform_176_element14\" class=\"wdform-label\">Choisir :<\/label><\/div><div class=\"wdform-element-section wd-flex wdform_select wd-flex-row wd-width-70\" style=\"max-width: 200px;\"><select class=\"wd-width-100\" id=\"wdform_176_element14\" name=\"wdform_176_element14\" ><option value=\"\" selected=\"selected\">Select value<\/option><option value=\"Examen et nettoyage\" >Examen et nettoyage<\/option><option value=\"Urgence\" >Urgence<\/option><option value=\"Consultation\" >Consultation<\/option><option value=\"Autre\" >Autre<\/option><\/select><\/div><\/div><\/div><div wdid=\"29\" class=\"wdform_row \"><div type=\"type_textarea\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30 \" style=\"max-width: 100px;\">    <label  for=\"wdform_29_element14\" class=\"wdform-label\">Specifi\u00e9 :<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-width-70\" style=\"max-width: 200px;\"><textarea class=\"wd-width-100\"                      id=\"wdform_29_element14\"                      name=\"wdform_29_element14\"                      placeholder=\"\"                      style=\"height: 100px;\"                      ><\/textarea><\/div><\/div><\/div><div wdid=\"183\" class=\"wdform_row \" style=\"\"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 200px;\">    <label  class=\"wdform-label\">Craignez-vous les traitements dentaires ? :<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_183_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_183_element140\" name=\"wdform_183_element14\" value=\"Pas du tout\" onclick=\"set_default(&quot;wdform_183&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_183_element140\"><span><\/span>Pas du tout<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_183_element141\" name=\"wdform_183_element14\" value=\"Un peu\" onclick=\"set_default(&quot;wdform_183&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_183_element141\"><span><\/span>Un peu<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_183_element142\" name=\"wdform_183_element14\" value=\"Beaucoup\" onclick=\"set_default(&quot;wdform_183&quot;,&quot;2&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_183_element142\"><span><\/span>Beaucoup<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"31\" class=\"wdform_row \"><div type=\"type_text\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-row wd-align-items-center\" style=\"max-width: 100px;\">    <label  for=\"wdform_31_element14\" class=\"wdform-label\">Pr\u00e9cisez :<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-align-items-center wd-width-70\" style=\"max-width: 200px;\"><input type=\"text\"                           class=\"wd-width-100\"                           id=\"wdform_31_element14\"                           name=\"wdform_31_element14\"                           value=\"\"                           title=\"\"                           placeholder=\"\"                                                       \/><\/div><\/div><\/div><div wdid=\"184\" class=\"wdform_row \" style=\"\"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 100px;\">    <label  class=\"wdform-label\">Derni\u00e8re visite :<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_184_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_184_element140\" name=\"wdform_184_element14\" value=\"0-6 mois\" onclick=\"set_default(&quot;wdform_184&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_184_element140\"><span><\/span>0-6 mois<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_184_element141\" name=\"wdform_184_element14\" value=\"6-12 mois\" onclick=\"set_default(&quot;wdform_184&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_184_element141\"><span><\/span>6-12 mois<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_184_element142\" name=\"wdform_184_element14\" value=\"+ 12 mois\" onclick=\"set_default(&quot;wdform_184&quot;,&quot;2&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_184_element142\"><span><\/span>+ 12 mois<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"119\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 300px;\">    <label  class=\"wdform-label\">Avec radiographie dentaire panoramique (grande radiographie) ? :<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_119_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_119_element140\" name=\"wdform_119_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_119&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_119_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_119_element141\" name=\"wdform_119_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_119&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_119_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"120\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 300px;\">    <label  class=\"wdform-label\">Avec radiographies dentaires intra-orales (petites radiographies) ? :<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_120_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_120_element140\" name=\"wdform_120_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_120&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_120_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_120_element141\" name=\"wdform_120_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_120&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_120_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"35\" class=\"wdform_row \"><div type=\"type_editor\" class=\"wdform-field\"><div data-canvas-width=\"1054.0937735294124\"><div data-canvas-width=\"1067.655573529412\"><em><strong>Ce questionnaire permettra au dentiste et \u00e0 son personnel de prodiguer les meilleurs soins possibles et de r\u00e9duire le risque de complication(s)<\/strong><\/em><\/div><div data-canvas-width=\"950.8102500000003\"><em><strong>m\u00e9dicale(s). Il est de l\u2019int\u00e9r\u00eat du patient d\u2019y r\u00e9pondre avec attention et d\u2019aviser le dentiste de tout changement \u00e0 son \u00e9tat de sant\u00e9.<\/strong><\/em><\/div><\/div><\/div><\/div><div wdid=\"36\" class=\"wdform_row \"><div type=\"type_editor\" class=\"wdform-field\"><p><strong>Ant\u00e9c\u00e9dents m\u00e9dicaux :<\/strong><\/p><\/div><\/div><div wdid=\"123\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 300px;\">    <label  class=\"wdform-label\">Souhaitez-vous discuter en priv\u00e9 avec votre dentiste ? :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_123_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_123_element140\" name=\"wdform_123_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_123&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_123_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_123_element141\" name=\"wdform_123_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_123&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_123_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"40\" class=\"wdform_row \"><div type=\"type_text\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-row wd-align-items-center\" style=\"max-width: 100px;\">    <label  for=\"wdform_40_element14\" class=\"wdform-label\">Raison, d\u00e9tails et date :<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-align-items-center wd-width-70\" style=\"max-width: 200px;\"><input type=\"text\"                           class=\"wd-width-100\"                           id=\"wdform_40_element14\"                           name=\"wdform_40_element14\"                           value=\"\"                           title=\"\"                           placeholder=\"\"                                                       \/><\/div><\/div><\/div><div wdid=\"124\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 300px;\">    <label  class=\"wdform-label\">Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 op\u00e9r\u00e9 ou hospitalis\u00e9 ? :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_124_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_124_element140\" name=\"wdform_124_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_124&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_124_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_124_element141\" name=\"wdform_124_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_124&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_124_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"42\" class=\"wdform_row \"><div type=\"type_text\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-row wd-align-items-center\" style=\"max-width: 100px;\">    <label  for=\"wdform_42_element14\" class=\"wdform-label\">Raison, d\u00e9tails et date:<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-align-items-center wd-width-70\" style=\"max-width: 200px;\"><input type=\"text\"                           class=\"wd-width-100\"                           id=\"wdform_42_element14\"                           name=\"wdform_42_element14\"                           value=\"\"                           title=\"\"                           placeholder=\"\"                                                       \/><\/div><\/div><\/div><div wdid=\"126\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 300px;\">    <label  class=\"wdform-label\">Avez-vous des proth\u00e8ses articulaires (hanche, genou, etc.) ? :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_126_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_126_element140\" name=\"wdform_126_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_126&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_126_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_126_element141\" name=\"wdform_126_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_126&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_126_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"44\" class=\"wdform_row \"><div type=\"type_text\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-row wd-align-items-center\" style=\"max-width: 100px;\">    <label  for=\"wdform_44_element14\" class=\"wdform-label\">Raison , d\u00e9tails et date :<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-align-items-center wd-width-70\" style=\"max-width: 200px;\"><input type=\"text\"                           class=\"wd-width-100\"                           id=\"wdform_44_element14\"                           name=\"wdform_44_element14\"                           value=\"\"                           title=\"\"                           placeholder=\"\"                                                       \/><\/div><\/div><\/div><div wdid=\"127\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 300px;\">    <label  class=\"wdform-label\">Avez-vous pris ou perdu beaucoup de poids derni\u00e8rement ? :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_127_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_127_element140\" name=\"wdform_127_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_127&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_127_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_127_element141\" name=\"wdform_127_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_127&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_127_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"46\" class=\"wdform_row \"><div type=\"type_text\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-row wd-align-items-center\" style=\"max-width: 100px;\">    <label  for=\"wdform_46_element14\" class=\"wdform-label\">Raison, d\u00e9tails et date  :<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-align-items-center wd-width-70\" style=\"max-width: 200px;\"><input type=\"text\"                           class=\"wd-width-100\"                           id=\"wdform_46_element14\"                           name=\"wdform_46_element14\"                           value=\"\"                           title=\"\"                           placeholder=\"\"                                                       \/><\/div><\/div><\/div><div wdid=\"128\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 150px;\">    <label  class=\"wdform-label\">\u00cates-vous enceinte ? :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_128_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_128_element140\" name=\"wdform_128_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_128&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_128_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_128_element141\" name=\"wdform_128_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_128&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_128_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"129\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 150px;\">    <label  class=\"wdform-label\">Allaitez-vous ? :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_129_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_129_element140\" name=\"wdform_129_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_129&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_129_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_129_element141\" name=\"wdform_129_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_129&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_129_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"130\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 300px;\">    <label  class=\"wdform-label\">Prenez-vous des produits naturels ou hom\u00e9opathiques ? :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_130_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_130_element140\" name=\"wdform_130_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_130&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_130_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_130_element141\" name=\"wdform_130_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_130&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_130_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"52\" class=\"wdform_row \"><div type=\"type_text\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-row wd-align-items-center\" style=\"max-width: 100px;\">    <label  for=\"wdform_52_element14\" class=\"wdform-label\">Pr\u00e9cisez  :<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-align-items-center wd-width-70\" style=\"max-width: 200px;\"><input type=\"text\"                           class=\"wd-width-100\"                           id=\"wdform_52_element14\"                           name=\"wdform_52_element14\"                           value=\"\"                           title=\"\"                           placeholder=\"\"                                                       \/><\/div><\/div><\/div><div wdid=\"131\" class=\"wdform_row \" style=\"\"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 200px;\">    <label  class=\"wdform-label\">Prenez-vous des m\u00e9dicaments ? :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_131_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_131_element140\" name=\"wdform_131_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_131&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_131_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_131_element141\" name=\"wdform_131_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_131&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_131_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"178\" class=\"wdform_row \" style=\"\"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 200px;\">    <label  class=\"wdform-label\">Prenez-vous des anovulants :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_178_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_178_element140\" name=\"wdform_178_element14\" value=\"Pilulles\" onclick=\"set_default(&quot;wdform_178&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_178_element140\"><span><\/span>Pilulles<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_178_element141\" name=\"wdform_178_element14\" value=\"Hormones\" onclick=\"set_default(&quot;wdform_178&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_178_element141\"><span><\/span>Hormones<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_178_element142\" name=\"wdform_178_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_178&quot;,&quot;2&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_178_element142\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"55\" class=\"wdform_row \"><div type=\"type_textarea\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30 \" style=\"max-width: 300px;\">    <label  for=\"wdform_55_element14\" class=\"wdform-label\">Veuillez indiquer tous les m\u00e9dicaments (incluant anovulants et hormones) pris en ce moment ou au cours des 12 derniers mois :<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-width-70\" style=\"max-width: 200px;\"><textarea class=\"wd-width-100\"                      id=\"wdform_55_element14\"                      name=\"wdform_55_element14\"                      placeholder=\"\"                      style=\"height: 100px;\"                      ><\/textarea><\/div><\/div><\/div><div wdid=\"56\" class=\"wdform_row \"><div type=\"type_editor\" class=\"wdform-field\"><p><strong>Veuillez cocher Oui ou Non pour chacune des conditions actuelles ou pass\u00e9es.<\/strong><\/p><\/div><\/div><div wdid=\"132\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 300px;\">    <label  class=\"wdform-label\">Probl\u00e8mes sanguins(h\u00e9mophilie, an\u00e9mie, saignements prolong\u00e9s) :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_132_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_132_element140\" name=\"wdform_132_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_132&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_132_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_132_element141\" name=\"wdform_132_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_132&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_132_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"59\" class=\"wdform_row \"><div type=\"type_editor\" class=\"wdform-field\"><p><strong>Conditions cardiaques<\/strong><\/p><\/div><\/div><div wdid=\"133\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 300px;\">    <label  class=\"wdform-label\">Infarctus, angine, chirurgie, etc. :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_133_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_133_element140\" name=\"wdform_133_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_133&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_133_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_133_element141\" name=\"wdform_133_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_133&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_133_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"134\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 200px;\">    <label  class=\"wdform-label\">Infection du c\u0153ur (endocardite) :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_134_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_134_element140\" name=\"wdform_134_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_134&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_134_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_134_element141\" name=\"wdform_134_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_134&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_134_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"135\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 300px;\">    <label  class=\"wdform-label\">Chirurgie pour poser ou r\u00e9parer valve\/valvule :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_135_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_135_element140\" name=\"wdform_135_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_135&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_135_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_135_element141\" name=\"wdform_135_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_135&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_135_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"179\" class=\"wdform_row \" style=\"\"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 300px;\">    <label  class=\"wdform-label\">Tension art\u00e9rielle (pression) :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_179_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_179_element140\" name=\"wdform_179_element14\" value=\"Haute\" onclick=\"set_default(&quot;wdform_179&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_179_element140\"><span><\/span>Haute<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_179_element141\" name=\"wdform_179_element14\" value=\"Basse\" onclick=\"set_default(&quot;wdform_179&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_179_element141\"><span><\/span>Basse<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_179_element142\" name=\"wdform_179_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_179&quot;,&quot;2&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_179_element142\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"136\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 150px;\">    <label  class=\"wdform-label\">\u00c9tourdissements, \u00e9vanouissements :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_136_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_136_element140\" name=\"wdform_136_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_136&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_136_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_136_element141\" name=\"wdform_136_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_136&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_136_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"137\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 150px;\">    <label  class=\"wdform-label\">Maux de t\u00eate fr\u00e9quents :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_137_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_137_element140\" name=\"wdform_137_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_137&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_137_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_137_element141\" name=\"wdform_137_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_137&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_137_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"138\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 200px;\">    <label  class=\"wdform-label\">Douleur \u00e0 l\u2019articulation de la m\u00e2choire :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_138_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_138_element140\" name=\"wdform_138_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_138&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_138_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_138_element141\" name=\"wdform_138_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_138&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_138_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"139\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 300px;\">    <label  class=\"wdform-label\">Probl\u00e8mes de foie (h\u00e9patite A,B,C, cirrhose, etc.) :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_139_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_139_element140\" name=\"wdform_139_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_139&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_139_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_139_element141\" name=\"wdform_139_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_139&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_139_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"140\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 300px;\">    <label  class=\"wdform-label\">Troubles ou maladies du syst\u00e8me digestif :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_140_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_140_element140\" name=\"wdform_140_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_140&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_140_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_140_element141\" name=\"wdform_140_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_140&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_140_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"68\" class=\"wdform_row \"><div type=\"type_text\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-row wd-align-items-center\" style=\"max-width: 200px;\">    <label  for=\"wdform_68_element14\" class=\"wdform-label\">Pr\u00e9cisez les troubles ou maladies :<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-align-items-center wd-width-70\" style=\"max-width: 200px;\"><input type=\"text\"                           class=\"wd-width-100\"                           id=\"wdform_68_element14\"                           name=\"wdform_68_element14\"                           value=\"\"                           title=\"\"                           placeholder=\"\"                                                       \/><\/div><\/div><\/div><div wdid=\"185\" class=\"wdform_row \" style=\"\"><div type=\"type_checkbox\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 150px;\">    <label  class=\"wdform-label\">Troubles d\u2019estomac :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_185_element14\" value=\"\" \/><div class=\"checkbox-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"checkbox\"  id=\"wdform_185_element140\" name=\"wdform_185_element140\" value=\"Ulc\u00e8re\"    \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_185_element140\"><span><\/span>Ulc\u00e8re<\/label><\/div><div class=\"checkbox-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"checkbox\"  id=\"wdform_185_element141\" name=\"wdform_185_element141\" value=\"Reflux\"    \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_185_element141\"><span><\/span>Reflux<\/label><\/div><div class=\"checkbox-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"checkbox\"  id=\"wdform_185_element142\" name=\"wdform_185_element142\" value=\"Non\"    \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_185_element142\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"141\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 150px;\">    <label  class=\"wdform-label\">Troubles du rein :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_141_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_141_element140\" name=\"wdform_141_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_141&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_141_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_141_element141\" name=\"wdform_141_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_141&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_141_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"142\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 150px;\">    <label  class=\"wdform-label\">Diab\u00e8tes :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_142_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_142_element140\" name=\"wdform_142_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_142&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_142_element140\"><span><\/span>Non<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_142_element141\" name=\"wdform_142_element14\" value=\"Type I\" onclick=\"set_default(&quot;wdform_142&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_142_element141\"><span><\/span>Type I<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_142_element142\" name=\"wdform_142_element14\" value=\"Type II\" onclick=\"set_default(&quot;wdform_142&quot;,&quot;2&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_142_element142\"><span><\/span>Type II<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"143\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 150px;\">    <label  class=\"wdform-label\">Troubles thyro\u00efdiens :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_143_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_143_element140\" name=\"wdform_143_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_143&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_143_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_143_element141\" name=\"wdform_143_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_143&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_143_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"144\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 150px;\">    <label  class=\"wdform-label\">Cancer (tumeur) :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_144_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_144_element140\" name=\"wdform_144_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_144&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_144_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_144_element141\" name=\"wdform_144_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_144&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_144_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"74\" class=\"wdform_row \"><div type=\"type_text\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-row wd-align-items-center\" style=\"max-width: 200px;\">    <label  for=\"wdform_74_element14\" class=\"wdform-label\">Pr\u00e9cisez le type de cancer :<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-align-items-center wd-width-70\" style=\"max-width: 200px;\"><input type=\"text\"                           class=\"wd-width-100\"                           id=\"wdform_74_element14\"                           name=\"wdform_74_element14\"                           value=\"\"                           title=\"\"                           placeholder=\"\"                                                       \/><\/div><\/div><\/div><div wdid=\"145\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 150px;\">    <label  class=\"wdform-label\">Chimioth\u00e9rapie :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_145_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_145_element140\" name=\"wdform_145_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_145&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_145_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_145_element141\" name=\"wdform_145_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_145&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_145_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"146\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 360px;\">    <label  class=\"wdform-label\">Infections transmissibles sexuellement et par le sang (ITSS) :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_146_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_146_element140\" name=\"wdform_146_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_146&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_146_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_146_element141\" name=\"wdform_146_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_146&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_146_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"77\" class=\"wdform_row \"><div type=\"type_text\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-row wd-align-items-center\" style=\"max-width: 100px;\">    <label  for=\"wdform_77_element14\" class=\"wdform-label\">Pr\u00e9cisez :  <\/label><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-align-items-center wd-width-70\" style=\"max-width: 200px;\"><input type=\"text\"                           class=\"wd-width-100\"                           id=\"wdform_77_element14\"                           name=\"wdform_77_element14\"                           value=\"\"                           title=\"\"                           placeholder=\"\"                                                       \/><\/div><\/div><\/div><div wdid=\"147\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 150px;\">    <label  class=\"wdform-label\">Maladies de peau :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_147_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_147_element140\" name=\"wdform_147_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_147&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_147_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_147_element141\" name=\"wdform_147_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_147&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_147_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"148\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 200px;\">    <label  class=\"wdform-label\">Probl\u00e8mes oculaires (yeux) :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_148_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_148_element140\" name=\"wdform_148_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_148&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_148_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_148_element141\" name=\"wdform_148_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_148&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_148_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"149\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 150px;\">    <label  class=\"wdform-label\">Maux d\u2019oreilles :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_149_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_149_element140\" name=\"wdform_149_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_149&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_149_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_149_element141\" name=\"wdform_149_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_149&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_149_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"150\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 100px;\">    <label  class=\"wdform-label\">Arthrite :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_150_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_150_element140\" name=\"wdform_150_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_150&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_150_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_150_element141\" name=\"wdform_150_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_150&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_150_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"181\" class=\"wdform_row \" style=\"\"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-column\" style=\"max-width: 150px;\">    <label  class=\"wdform-label\">Ost\u00e9oporose :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-column wd-width-70\" ><div class=\"wd-flex wd-flex-column\"><input type=\"hidden\" name=\"wdform_181_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row\"><input type=\"radio\"  id=\"wdform_181_element140\" name=\"wdform_181_element14\" value=\"Pr\u00e9vention\/traitement (p. ex. : comprim\u00e9s)\" onclick=\"set_default(&quot;wdform_181&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_181_element140\"><span><\/span>Pr\u00e9vention\/traitement (p. ex. : comprim\u00e9s)<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row\"><input type=\"radio\"  id=\"wdform_181_element141\" name=\"wdform_181_element14\" value=\"Injection annuelle ou mensuelle\" onclick=\"set_default(&quot;wdform_181&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_181_element141\"><span><\/span>Injection annuelle ou mensuelle<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row\"><input type=\"radio\"  id=\"wdform_181_element142\" name=\"wdform_181_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_181&quot;,&quot;2&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row\" for=\"wdform_181_element142\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"151\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 150px;\">    <label  class=\"wdform-label\">Douleur chronique :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_151_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_151_element140\" name=\"wdform_151_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_151&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_151_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_151_element141\" name=\"wdform_151_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_151&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_151_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"152\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 100px;\">    <label  class=\"wdform-label\">\u00c9pilepsie :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_152_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_152_element140\" name=\"wdform_152_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_152&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_152_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_152_element141\" name=\"wdform_152_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_152&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_152_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"153\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 260px;\">    <label  class=\"wdform-label\">Troubles ou maladies du syst\u00e8me nerveux :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_153_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_153_element140\" name=\"wdform_153_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_153&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_153_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_153_element141\" name=\"wdform_153_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_153&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_153_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"154\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 250px;\">    <label  class=\"wdform-label\">Troubles ou maladies psychiatriques :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_154_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_154_element140\" name=\"wdform_154_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_154&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_154_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_154_element141\" name=\"wdform_154_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_154&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_154_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"155\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 200px;\">    <label  class=\"wdform-label\">Rhumes fr\u00e9quents ou sinusite :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_155_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_155_element140\" name=\"wdform_155_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_155&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_155_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_155_element141\" name=\"wdform_155_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_155&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_155_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"156\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 250px;\">    <label  class=\"wdform-label\">Rhume des foins\/allergies saisonni\u00e8res : <\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_156_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_156_element140\" name=\"wdform_156_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_156&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_156_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_156_element141\" name=\"wdform_156_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_156&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_156_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"157\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 100px;\">    <label  class=\"wdform-label\">Asthme :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_157_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_157_element140\" name=\"wdform_157_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_157&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_157_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_157_element141\" name=\"wdform_157_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_157&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_157_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"158\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 200px;\">    <label  class=\"wdform-label\">Tuberculose ou probl\u00e8mes pulmonaires :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_158_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_158_element140\" name=\"wdform_158_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_158&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_158_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_158_element141\" name=\"wdform_158_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_158&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_158_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"91\" class=\"wdform_row \"><div type=\"type_editor\" class=\"wdform-field\"><p><strong>Allergie ou manifestation \u00e0 ces produits :<\/strong><\/p><\/div><\/div><div wdid=\"159\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 100px;\">    <label  class=\"wdform-label\">Latex :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_159_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_159_element140\" name=\"wdform_159_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_159&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_159_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_159_element141\" name=\"wdform_159_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_159&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_159_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"160\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 100px;\">    <label  class=\"wdform-label\">P\u00e9nicilline :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_160_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_160_element140\" name=\"wdform_160_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_160&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_160_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_160_element141\" name=\"wdform_160_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_160&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_160_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"161\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 150px;\">    <label  class=\"wdform-label\">Autres antibiotiques :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_161_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_161_element140\" name=\"wdform_161_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_161&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_161_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_161_element141\" name=\"wdform_161_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_161&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_161_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"186\" class=\"wdform_row \" style=\"\"><div type=\"type_text\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-row wd-align-items-center\" style=\"max-width: 100px;\">    <label  for=\"wdform_186_element14\" class=\"wdform-label\">Lesquels ?<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-align-items-center wd-width-70\" style=\"max-width: 200px;\"><input type=\"text\"                           class=\"wd-width-100\"                           id=\"wdform_186_element14\"                           name=\"wdform_186_element14\"                           value=\"\"                           title=\"\"                           placeholder=\"\"                                                       \/><\/div><\/div><\/div><div wdid=\"162\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 100px;\">    <label  class=\"wdform-label\">Cod\u00e9ine :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_162_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_162_element140\" name=\"wdform_162_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_162&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_162_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_162_element141\" name=\"wdform_162_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_162&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_162_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"163\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 100px;\">    <label  class=\"wdform-label\">Aspirine :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_163_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_163_element140\" name=\"wdform_163_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_163&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_163_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_163_element141\" name=\"wdform_163_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_163&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_163_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"164\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 100px;\">    <label  class=\"wdform-label\">Sulfamid\u00e9s :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_164_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_164_element140\" name=\"wdform_164_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_164&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_164_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_164_element141\" name=\"wdform_164_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_164&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_164_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"165\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 150px;\">    <label  class=\"wdform-label\">Anesth\u00e9siques :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_165_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_165_element140\" name=\"wdform_165_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_165&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_165_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_165_element141\" name=\"wdform_165_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_165&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_165_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"166\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 100px;\">    <label  class=\"wdform-label\">Alimentaires :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_166_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_166_element140\" name=\"wdform_166_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_166&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_166_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_166_element141\" name=\"wdform_166_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_166&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_166_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"167\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 200px;\">    <label  class=\"wdform-label\">Produits contenant de l'iode :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_167_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_167_element140\" name=\"wdform_167_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_167&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_167_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_167_element141\" name=\"wdform_167_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_167&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_167_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"101\" class=\"wdform_row \"><div type=\"type_text\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-row wd-align-items-center\" style=\"max-width: 100px;\">    <label  for=\"wdform_101_element14\" class=\"wdform-label\">Autre :<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-align-items-center wd-width-70\" style=\"max-width: 200px;\"><input type=\"text\"                           class=\"wd-width-100\"                           id=\"wdform_101_element14\"                           name=\"wdform_101_element14\"                           value=\"\"                           title=\"\"                           placeholder=\"\"                                                       \/><\/div><\/div><\/div><div wdid=\"102\" class=\"wdform_row \"><div type=\"type_textarea\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30 \" style=\"max-width: 200px;\">    <label  for=\"wdform_102_element14\" class=\"wdform-label\">Autres conditions m\u00e9dicales \u00e0 mentionner :<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-width-70\" style=\"max-width: 200px;\"><textarea class=\"wd-width-100\"                      id=\"wdform_102_element14\"                      name=\"wdform_102_element14\"                      placeholder=\"\"                      style=\"height: 100px;\"                      ><\/textarea><\/div><\/div><\/div><div wdid=\"103\" class=\"wdform_row \"><div type=\"type_editor\" class=\"wdform-field\"><p><strong>Autres aspects :<\/strong><\/p><\/div><\/div><div wdid=\"168\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 100px;\">    <label  class=\"wdform-label\">Ronflez-vous ? :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_168_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_168_element140\" name=\"wdform_168_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_168&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_168_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_168_element141\" name=\"wdform_168_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_168&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_168_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"169\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 250px;\">    <label  class=\"wdform-label\">Souffrez-vous d\u2019apn\u00e9e du sommeil ? :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_169_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_169_element140\" name=\"wdform_169_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_169&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_169_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_169_element141\" name=\"wdform_169_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_169&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_169_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"170\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 100px;\">    <label  class=\"wdform-label\">Fumez-vous ? :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_170_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_170_element140\" name=\"wdform_170_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_170&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_170_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_170_element141\" name=\"wdform_170_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_170&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_170_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"107\" class=\"wdform_row \"><div type=\"type_text\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-row wd-align-items-center\" style=\"max-width: 200px;\">    <label  for=\"wdform_107_element14\" class=\"wdform-label\">Combien de cigarettes \/jour :<\/label><\/div><div class=\"wdform-element-section wd-flex  wd-flex-row wd-align-items-center wd-width-70\" style=\"max-width: 200px;\"><input type=\"text\"                           class=\"wd-width-100\"                           id=\"wdform_107_element14\"                           name=\"wdform_107_element14\"                           value=\"\"                           title=\"\"                           placeholder=\"\"                                                       \/><\/div><\/div><\/div><div wdid=\"171\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 150px;\">    <label  class=\"wdform-label\">Ancien-fumeur ?:<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_171_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_171_element140\" name=\"wdform_171_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_171&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_171_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_171_element141\" name=\"wdform_171_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_171&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_171_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"172\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 200px;\">    <label  class=\"wdform-label\">Consommez-vous de l\u2019alcool ? :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_172_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_172_element140\" name=\"wdform_172_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_172&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_172_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_172_element141\" name=\"wdform_172_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_172&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_172_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"182\" class=\"wdform_row \" style=\"\"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 150px;\">    <label  class=\"wdform-label\">Fr\u00e9quence :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_182_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_182_element140\" name=\"wdform_182_element14\" value=\"Jour\" onclick=\"set_default(&quot;wdform_182&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_182_element140\"><span><\/span>Jour<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_182_element141\" name=\"wdform_182_element14\" value=\"Semaine\" onclick=\"set_default(&quot;wdform_182&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_182_element141\"><span><\/span>Semaine<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_182_element142\" name=\"wdform_182_element14\" value=\"Mois\" onclick=\"set_default(&quot;wdform_182&quot;,&quot;2&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_182_element142\"><span><\/span>Mois<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"173\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 210px;\">    <label  class=\"wdform-label\">Consommez-vous des drogues ? :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_173_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_173_element140\" name=\"wdform_173_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_173&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_173_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_173_element141\" name=\"wdform_173_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_173&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_173_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"174\" class=\"wdform_row \"><div type=\"type_radio\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 200px;\">    <label  class=\"wdform-label\">Prenez-vous de la m\u00e9thadone ? :<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_174_element14\" value=\"\" \/><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_174_element140\" name=\"wdform_174_element14\" value=\"Oui\" onclick=\"set_default(&quot;wdform_174&quot;,&quot;0&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_174_element140\"><span><\/span>Oui<\/label><\/div><div class=\"radio-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"radio\"  id=\"wdform_174_element141\" name=\"wdform_174_element14\" value=\"Non\" onclick=\"set_default(&quot;wdform_174&quot;,&quot;1&quot;,&quot;14&quot;); \"   \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_174_element141\"><span><\/span>Non<\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"187\" class=\"wdform_row \" style=\"\"><div type=\"type_editor\" class=\"wdform-field\"><div data-canvas-width=\"1165.7233411764707\"><strong>Je consens \u00e0 ce que le dentiste et son personnel recueillent des renseignements pertinents et compatibles \u00e0 l\u2019objet du dossier aupr\u00e8s des<\/strong><\/div><div data-canvas-width=\"947.7501764705884\"><strong>professionnels de la sant\u00e9 \u00e9num\u00e9r\u00e9s ci-dessus ou qu\u2019ils communiquent de tels renseignements \u00e0 ces derniers.<\/strong><\/div><\/div><\/div><div wdid=\"188\" class=\"wdform_row \" style=\"\"><div type=\"type_checkbox\" class=\"wdform-field wd-width-100 wd-flex wd-flex-row\"><div class=\"wdform-label-section wd-width-30  wd-flex-wrap wd-flex-row\" style=\"max-width: 300px;\">    <label  class=\"wdform-label\">J\u2019ai rempli ce questionnaire m\u00e9dicodentaire au meilleur de ma connaissance.<\/label><span class=\"wdform-required\">*<\/span><\/div><div class=\"wdform-element-section wd-flex  wd-flex-wrap wd-flex-row wd-width-70\" ><div class=\"wd-flex wd-flex-row\"><input type=\"hidden\" name=\"wdform_188_element14\" value=\"\" \/><div class=\"checkbox-div wd-choice wd-flex wd-flex-row-reverse wd-justify-content\"><input type=\"checkbox\"  id=\"wdform_188_element140\" name=\"wdform_188_element140\" value=\"\"    \/><label class=\"wd-align-items-center wd-flex wd-flex-row-reverse wd-justify-content wd-width-100\" for=\"wdform_188_element140\"><span><\/span><\/label><\/div><\/div><\/div><\/div><\/div><div wdid=\"115\" class=\"wdform_row \"><div type=\"type_submit_reset\" class=\"wdform-field wd-width-100 wd-flex wd-flex-column\"><div class=\"wdform-element-section wd-flex  wd-flex-row wd-width-100\" ><button  type=\"button\" class=\"button-submit\" onclick=\"fm_submit_form('14');\"  data-ajax=\"0\"><span class=\"fm-submit-loading spinner fm-ico-spinner\"><\/span>Envoyer<\/button><button  type=\"button\" class=\"button-reset \" onclick=\"fm_reset_form(14);\" >Reset<\/button><\/div><\/div><\/div><\/div><\/div><div valign=\"top\" class=\"wdform_footer\" style=\"width: 100%;\"><div style=\"width: 100%;\"><div style=\"width: 100%; display: table;\"><div style=\"display: table-row-group;\"><div id=\"14page_nav1\" style=\"display: table-row;\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"wdform_preload\"><\/div><\/form><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-419","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v24.4 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Questionnaire d&#039;inscription confidentiel - 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