{"id":76,"date":"2026-08-31T17:09:52","date_gmt":"2026-08-31T17:09:52","guid":{"rendered":"https:\/\/cliniquedentairesoleil-brossard.com\/?page_id=76"},"modified":"2026-08-31T19:31:47","modified_gmt":"2026-08-31T19:31:47","slug":"questionnaire-medical","status":"publish","type":"page","link":"https:\/\/cliniquedentairesoleil-brossard.com\/en\/questionnaire-medical\/","title":{"rendered":"Questionnaire medical"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"76\" class=\"elementor elementor-76\">\n\t\t\t\t<div class=\"elementor-element elementor-element-38394b7 e-flex e-con-boxed e-con e-parent\" data-id=\"38394b7\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-bd96e82 elementor-widget elementor-widget-html\" data-id=\"bd96e82\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t\t<section class=\"questionnaire-hero\">\r\n  <div class=\"wrap\">\r\n    <span class=\"eyebrow\">Nouveaux patients<\/span>\r\n    <h1>Questionnaire m\u00e9dical<\/h1>\r\n    <p class=\"lead\">\r\n      Afin de pr\u00e9parer votre visite, veuillez remplir ce questionnaire au meilleur de votre connaissance.\r\n      Ces renseignements nous aident \u00e0 vous offrir des soins s\u00e9curitaires et adapt\u00e9s \u00e0 votre situation.\r\n    <\/p>\r\n      <h3>Avant de commencer<\/h3>\r\n      <p>\r\n        Veuillez pr\u00e9voir quelques minutes pour compl\u00e9ter le formulaire.\r\n        Si votre \u00e9tat de sant\u00e9 change, informez notre \u00e9quipe lors de votre prochaine visite.\r\n      <\/p>\r\n  <\/div>\r\n<\/section>\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-d323352 e-flex e-con-boxed e-con e-parent\" data-id=\"d323352\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-60db7b7 elementor-widget elementor-widget-wpforms\" data-id=\"60db7b7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"wpforms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-64\"><form id=\"wpforms-form-64\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"64\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/en\/wp-json\/wp\/v2\/pages\/76\" data-token=\"d21dace090672c2a7af6b496b564883f\" data-token-time=\"1789972234\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-64-field_1-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-64-field_1\">Pr\u00e9nom <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-64-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" aria-errormessage=\"wpforms-64-field_1-error\" required><\/div><div id=\"wpforms-64-field_2-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-64-field_2\">Nom <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-64-field_2\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][2]\" aria-errormessage=\"wpforms-64-field_2-error\" required><\/div><div id=\"wpforms-64-field_6-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"6\"><fieldset><legend class=\"wpforms-field-label\">Genre <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_6\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_6_1\" name=\"wpforms[fields][6]\" value=\"F\" aria-errormessage=\"wpforms-64-field_6_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_6_1\">F<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_6_2\" name=\"wpforms[fields][6]\" value=\"M\" aria-errormessage=\"wpforms-64-field_6_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_6_2\">M<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_6_3\" name=\"wpforms[fields][6]\" value=\"X\" aria-errormessage=\"wpforms-64-field_6_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_6_3\">X<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-64-field_3\">Date de naissance (JJ\/MM\/AAAA) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-64-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" aria-errormessage=\"wpforms-64-field_3-error\" required><\/div><div id=\"wpforms-64-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-64-field_4\">Num\u00e9ro d&#039;assurance maladie <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-64-field_4\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][4]\" aria-errormessage=\"wpforms-64-field_4-error\" aria-describedby=\"wpforms-64-field_4-description\" required><div id=\"wpforms-64-field_4-description\" class=\"wpforms-field-description\">(Pour les patients de 10 ans et moins)<\/div><\/div><div id=\"wpforms-64-field_5-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-64-field_5\">Expiration <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-64-field_5\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][5]\" aria-errormessage=\"wpforms-64-field_5-error\" aria-describedby=\"wpforms-64-field_5-description\" required><div id=\"wpforms-64-field_5-description\" class=\"wpforms-field-description\">(Pour les patients de 10 ans et moins)<\/div><\/div><div id=\"wpforms-64-field_7-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-64-field_7\">Adresse <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-64-field_7\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][7]\" aria-errormessage=\"wpforms-64-field_7-error\" required><\/div><div id=\"wpforms-64-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-64-field_8\">Ville <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-64-field_8\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][8]\" aria-errormessage=\"wpforms-64-field_8-error\" required><\/div><div id=\"wpforms-64-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-64-field_9\">Province <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-64-field_9\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][9]\" aria-errormessage=\"wpforms-64-field_9-error\" required><\/div><div id=\"wpforms-64-field_10-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-64-field_10\">Code postal <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-64-field_10\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][10]\" aria-errormessage=\"wpforms-64-field_10-error\" required><\/div><div id=\"wpforms-64-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-64-field_11\">T\u00e9l\u00e9phone domicile <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-64-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" aria-errormessage=\"wpforms-64-field_11-error\" required><\/div><div id=\"wpforms-64-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-64-field_12\">T\u00e9l\u00e9phone cellulaire<\/label><input type=\"text\" id=\"wpforms-64-field_12\" class=\"wpforms-field-medium\" name=\"wpforms[fields][12]\" aria-errormessage=\"wpforms-64-field_12-error\" ><\/div><div id=\"wpforms-64-field_13-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-64-field_13\">Courriel <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-64-field_13\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][13]\" aria-errormessage=\"wpforms-64-field_13-error\" required><\/div><div id=\"wpforms-64-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-64-field_14\">Nom de la personne \u00e0 contacter en cas d&#039;urgence <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-64-field_14\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][14]\" aria-errormessage=\"wpforms-64-field_14-error\" required><\/div><div id=\"wpforms-64-field_15-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-64-field_15\">Lien avec le patient <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-64-field_15\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][15]\" aria-errormessage=\"wpforms-64-field_15-error\" required><\/div><div id=\"wpforms-64-field_16-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-64-field_16\">T\u00e9l\u00e9phone de la personne \u00e0 contacter en cas d&#039;urgence <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-64-field_16\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][16]\" aria-errormessage=\"wpforms-64-field_16-error\" required><\/div><div id=\"wpforms-64-field_17-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-64-field_17\">Raison de la visite <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-64-field_17\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][17]\" aria-errormessage=\"wpforms-64-field_17-error\" required><\/textarea><\/div><div id=\"wpforms-64-field_18-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"18\"><fieldset><legend class=\"wpforms-field-label\">Derni\u00e8re visite chez le dentiste <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_18\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_18_1\" name=\"wpforms[fields][18]\" value=\"0 \u00e0 6 mois\" aria-errormessage=\"wpforms-64-field_18_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_18_1\">0 \u00e0 6 mois<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_18_2\" name=\"wpforms[fields][18]\" value=\"6 \u00e0 12 mois\" aria-errormessage=\"wpforms-64-field_18_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_18_2\">6 \u00e0 12 mois<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_18_3\" name=\"wpforms[fields][18]\" value=\"Plus de 12 mois\" aria-errormessage=\"wpforms-64-field_18_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_18_3\">Plus de 12 mois<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_19-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-64-field_19\">Traitement(s) re\u00e7u(s) lors de votre derni\u00e8re visite <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-64-field_19\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][19]\" aria-errormessage=\"wpforms-64-field_19-error\" required><\/textarea><\/div><div id=\"wpforms-64-field_20-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"20\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous eu une radiographie dentaire panoramique? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_20\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_20_1\" name=\"wpforms[fields][20]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_20_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_20_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_20_2\" name=\"wpforms[fields][20]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_20_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_20_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_21-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"21\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous eu des radiographies dentaires intra-orales? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_21\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_21_1\" name=\"wpforms[fields][21]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_21_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_21_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_21_2\" name=\"wpforms[fields][21]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_21_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_21_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_22-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"22\"><fieldset><legend class=\"wpforms-field-label\">Craignez-vous les traitements dentaires? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_22\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_22_1\" name=\"wpforms[fields][22]\" value=\"Pas du tout\" aria-errormessage=\"wpforms-64-field_22_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_22_1\">Pas du tout<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_22_2\" name=\"wpforms[fields][22]\" value=\"Un peu\" aria-errormessage=\"wpforms-64-field_22_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_22_2\">Un peu<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_22_4\" name=\"wpforms[fields][22]\" value=\"Beaucoup\" aria-errormessage=\"wpforms-64-field_22_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_22_4\">Beaucoup<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_23-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-64-field_23\">Si oui ou si vous avez des pr\u00e9occupations, veuillez pr\u00e9ciser <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-64-field_23\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][23]\" aria-errormessage=\"wpforms-64-field_23-error\" required><\/textarea><\/div><div id=\"wpforms-64-field_24-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"24\"><fieldset><legend class=\"wpforms-field-label\">Souhaitez-vous discuter en priv\u00e9 avec votre dentiste? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_24\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_24_1\" name=\"wpforms[fields][24]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_24_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_24_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_24_3\" name=\"wpforms[fields][24]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_24_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_24_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_25-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"25\"><fieldset><legend class=\"wpforms-field-label\">\u00cates-vous suivi par un m\u00e9decin? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_25\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_25_1\" name=\"wpforms[fields][25]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_25_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_25_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_25_3\" name=\"wpforms[fields][25]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_25_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_25_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_26-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"26\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 op\u00e9r\u00e9 ou hospitalis\u00e9? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_26\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_26_1\" name=\"wpforms[fields][26]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_26_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_26_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_26_3\" name=\"wpforms[fields][26]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_26_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_26_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_27-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"27\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous des proth\u00e8ses articulaires, par exemple \u00e0 la hanche ou au genou? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_27\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_27_1\" name=\"wpforms[fields][27]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_27_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_27_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_27_3\" name=\"wpforms[fields][27]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_27_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_27_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_28-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"28\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous pris ou perdu beaucoup de poids derni\u00e8rement? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_28\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_28_1\" name=\"wpforms[fields][28]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_28_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_28_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_28_3\" name=\"wpforms[fields][28]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_28_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_28_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_29-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"29\"><fieldset><legend class=\"wpforms-field-label\">\u00cates-vous enceinte? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_29\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_29_1\" name=\"wpforms[fields][29]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_29_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_29_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_29_3\" name=\"wpforms[fields][29]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_29_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_29_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_30-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"30\"><fieldset><legend class=\"wpforms-field-label\">Allaitez-vous? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_30\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_30_1\" name=\"wpforms[fields][30]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_30_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_30_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_30_3\" name=\"wpforms[fields][30]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_30_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_30_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_31-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"31\"><fieldset><legend class=\"wpforms-field-label\">Prenez-vous des produits naturels ou hom\u00e9opathiques? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_31\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_31_1\" name=\"wpforms[fields][31]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_31_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_31_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_31_3\" name=\"wpforms[fields][31]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_31_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_31_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_32-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"32\"><fieldset><legend class=\"wpforms-field-label\">Prenez-vous des m\u00e9dicaments? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_32\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_32_1\" name=\"wpforms[fields][32]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_32_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_32_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_32_3\" name=\"wpforms[fields][32]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_32_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_32_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_33-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"33\"><fieldset><legend class=\"wpforms-field-label\">Prenez-vous des anovulants ou des hormones? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_33\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_33_1\" name=\"wpforms[fields][33]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_33_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_33_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_33_3\" name=\"wpforms[fields][33]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_33_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_33_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_34-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"34\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous des probl\u00e8mes sanguins, comme l\u2019h\u00e9mophilie, l\u2019an\u00e9mie ou des saignements prolong\u00e9s? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_34\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_34_1\" name=\"wpforms[fields][34]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_34_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_34_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_34_3\" name=\"wpforms[fields][34]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_34_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_34_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_72-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"72\"><label class=\"wpforms-field-label\" for=\"wpforms-64-field_72\">Veuillez indiquer tous les m\u00e9dicaments pris actuellement ou au cours des 12 derniers mois, ainsi que la raison <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-64-field_72\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][72]\" aria-errormessage=\"wpforms-64-field_72-error\" required><\/textarea><\/div><div id=\"wpforms-64-field_71-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"71\"><label class=\"wpforms-field-label\" for=\"wpforms-64-field_71\">Raison, d\u00e9tails et date concernant les r\u00e9ponses pr\u00e9c\u00e9dentes <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-64-field_71\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][71]\" aria-errormessage=\"wpforms-64-field_71-error\" required><\/textarea><\/div><div id=\"wpforms-64-field_35-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"35\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous d\u00e9j\u00e0 eu une infection du c\u0153ur, comme une endocardite? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_35\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_35_1\" name=\"wpforms[fields][35]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_35_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_35_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_35_3\" name=\"wpforms[fields][35]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_35_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_35_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_36-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"36\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous subi une chirurgie pour poser ou r\u00e9parer une valve ou valvule cardiaque? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_36\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_36_1\" name=\"wpforms[fields][36]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_36_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_36_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_36_3\" name=\"wpforms[fields][36]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_36_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_36_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_37-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"37\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous de la haute pression? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_37\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_37_1\" name=\"wpforms[fields][37]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_37_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_37_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_37_3\" name=\"wpforms[fields][37]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_37_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_37_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_38-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"38\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous de la basse pression? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_38\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_38_1\" name=\"wpforms[fields][38]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_38_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_38_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_38_3\" name=\"wpforms[fields][38]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_38_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_38_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_39-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"39\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous des \u00e9tourdissements ou des \u00e9vanouissements? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_39\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_39_1\" name=\"wpforms[fields][39]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_39_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_39_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_39_3\" name=\"wpforms[fields][39]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_39_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_39_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_40-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"40\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous des maux de t\u00eate fr\u00e9quents? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_40\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_40_1\" name=\"wpforms[fields][40]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_40_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_40_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_40_3\" name=\"wpforms[fields][40]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_40_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_40_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_41-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"41\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous des douleurs \u00e0 l\u2019articulation de la m\u00e2choire? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_41\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_41_1\" name=\"wpforms[fields][41]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_41_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_41_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_41_3\" name=\"wpforms[fields][41]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_41_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_41_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_42-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"42\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous des probl\u00e8mes de foie, comme une h\u00e9patite ou une cirrhose? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_42\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_42_1\" name=\"wpforms[fields][42]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_42_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_42_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_42_3\" name=\"wpforms[fields][42]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_42_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_42_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_43-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"43\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous des troubles ou maladies du syst\u00e8me digestif? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_43\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_43_1\" name=\"wpforms[fields][43]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_43_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_43_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_43_3\" name=\"wpforms[fields][43]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_43_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_43_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_73-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"73\"><label class=\"wpforms-field-label\" for=\"wpforms-64-field_73\">Si oui, veuillez pr\u00e9ciser<\/label><input type=\"text\" id=\"wpforms-64-field_73\" class=\"wpforms-field-medium\" name=\"wpforms[fields][73]\" aria-errormessage=\"wpforms-64-field_73-error\" ><\/div><div id=\"wpforms-64-field_44-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"44\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous un ulc\u00e8re d\u2019estomac? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_44\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_44_1\" name=\"wpforms[fields][44]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_44_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_44_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_44_3\" name=\"wpforms[fields][44]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_44_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_44_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_45-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"45\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous du reflux? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_45\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_45_1\" name=\"wpforms[fields][45]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_45_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_45_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_45_3\" name=\"wpforms[fields][45]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_45_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_45_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_46-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"46\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous des troubles du rein? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_46\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_46_1\" name=\"wpforms[fields][46]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_46_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_46_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_46_3\" name=\"wpforms[fields][46]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_46_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_46_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_47-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"47\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous du diab\u00e8te? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_47\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_47_1\" name=\"wpforms[fields][47]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_47_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_47_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_47_3\" name=\"wpforms[fields][47]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_47_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_47_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_48-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"48\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous des troubles thyro\u00efdiens? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_48\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_48_1\" name=\"wpforms[fields][48]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_48_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_48_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_48_3\" name=\"wpforms[fields][48]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_48_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_48_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_49-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"49\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous ou avez-vous d\u00e9j\u00e0 eu un cancer ou une tumeur? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_49\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_49_1\" name=\"wpforms[fields][49]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_49_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_49_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_49_3\" name=\"wpforms[fields][49]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_49_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_49_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_74-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"74\"><label class=\"wpforms-field-label\" for=\"wpforms-64-field_74\">Si oui, veuillez pr\u00e9ciser<\/label><input type=\"text\" id=\"wpforms-64-field_74\" class=\"wpforms-field-medium\" name=\"wpforms[fields][74]\" aria-errormessage=\"wpforms-64-field_74-error\" ><\/div><div id=\"wpforms-64-field_50-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"50\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous re\u00e7u de la radioth\u00e9rapie? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_50\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_50_1\" name=\"wpforms[fields][50]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_50_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_50_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_50_3\" name=\"wpforms[fields][50]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_50_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_50_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_51-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"51\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous re\u00e7u de la chimioth\u00e9rapie? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_51\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_51_1\" name=\"wpforms[fields][51]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_51_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_51_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_51_3\" name=\"wpforms[fields][51]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_51_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_51_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_52-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"52\"><fieldset><legend class=\"wpforms-field-label\">Souffrez-vous de s\u00e9cheresse de la bouche? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_52\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_52_1\" name=\"wpforms[fields][52]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_52_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_52_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_52_3\" name=\"wpforms[fields][52]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_52_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_52_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_76-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"76\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous ou avez-vous d\u00e9j\u00e0 eu une infection transmissible sexuellement ou par le sang? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_76\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_76_1\" name=\"wpforms[fields][76]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_76_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_76_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_76_3\" name=\"wpforms[fields][76]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_76_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_76_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_75-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"75\"><label class=\"wpforms-field-label\" for=\"wpforms-64-field_75\">Si oui, veuillez pr\u00e9ciser<\/label><input type=\"text\" id=\"wpforms-64-field_75\" class=\"wpforms-field-medium\" name=\"wpforms[fields][75]\" aria-errormessage=\"wpforms-64-field_75-error\" ><\/div><div id=\"wpforms-64-field_53-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"53\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous une maladie de peau? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_53\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_53_1\" name=\"wpforms[fields][53]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_53_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_53_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_53_3\" name=\"wpforms[fields][53]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_53_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_53_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_54-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"54\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous des probl\u00e8mes oculaires? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_54\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_54_1\" name=\"wpforms[fields][54]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_54_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_54_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_54_3\" name=\"wpforms[fields][54]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_54_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_54_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_55-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"55\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous des maux d\u2019oreilles? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_55\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_55_1\" name=\"wpforms[fields][55]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_55_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_55_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_55_3\" name=\"wpforms[fields][55]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_55_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_55_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_56-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"56\"><fieldset><legend class=\"wpforms-field-label\">Souffrez-vous d\u2019arthrite? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_56\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_56_1\" name=\"wpforms[fields][56]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_56_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_56_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_56_3\" name=\"wpforms[fields][56]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_56_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_56_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_57-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"57\"><fieldset><legend class=\"wpforms-field-label\">Souffrez-vous d\u2019ost\u00e9oporose? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_57\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_57_1\" name=\"wpforms[fields][57]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_57_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_57_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_57_3\" name=\"wpforms[fields][57]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_57_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_57_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_58-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"58\"><fieldset><legend class=\"wpforms-field-label\">Prenez-vous un traitement pr\u00e9ventif ou un m\u00e9dicament pour l\u2019ost\u00e9oporose? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_58\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_58_1\" name=\"wpforms[fields][58]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_58_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_58_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_58_3\" name=\"wpforms[fields][58]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_58_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_58_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_59-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"59\"><fieldset><legend class=\"wpforms-field-label\">Recevez-vous une injection annuelle ou mensuelle pour l\u2019ost\u00e9oporose? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_59\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_59_1\" name=\"wpforms[fields][59]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_59_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_59_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_59_3\" name=\"wpforms[fields][59]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_59_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_59_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_60-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"60\"><fieldset><legend class=\"wpforms-field-label\">Souffrez-vous de douleur chronique? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_60\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_60_1\" name=\"wpforms[fields][60]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_60_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_60_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_60_3\" name=\"wpforms[fields][60]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_60_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_60_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_61-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"61\"><fieldset><legend class=\"wpforms-field-label\">Souffrez-vous d\u2019\u00e9pilepsie? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_61\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_61_1\" name=\"wpforms[fields][61]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_61_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_61_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_61_3\" name=\"wpforms[fields][61]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_61_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_61_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_62-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"62\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous des troubles ou maladies du syst\u00e8me nerveux? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_62\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_62_1\" name=\"wpforms[fields][62]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_62_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_62_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_62_3\" name=\"wpforms[fields][62]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_62_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_62_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_63-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"63\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous des troubles ou maladies psychiatriques? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_63\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_63_1\" name=\"wpforms[fields][63]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_63_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_63_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_63_3\" name=\"wpforms[fields][63]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_63_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_63_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_64-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"64\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous des rhumes fr\u00e9quents ou de la sinusite? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_64\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_64_1\" name=\"wpforms[fields][64]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_64_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_64_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_64_3\" name=\"wpforms[fields][64]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_64_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_64_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_65-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"65\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous ou avez-vous d\u00e9j\u00e0 eu la tuberculose ou des probl\u00e8mes pulmonaires? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_65\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_65_1\" name=\"wpforms[fields][65]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_65_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_65_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_65_3\" name=\"wpforms[fields][65]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_65_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_65_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_66-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"66\"><fieldset><legend class=\"wpforms-field-label\">Souffrez-vous d\u2019asthme? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_66\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_66_1\" name=\"wpforms[fields][66]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_66_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_66_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_66_3\" name=\"wpforms[fields][66]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_66_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_66_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_67-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"67\"><fieldset><legend class=\"wpforms-field-label\">Souffrez-vous de rhume des foins ou d\u2019allergies saisonni\u00e8res? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_67\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_67_1\" name=\"wpforms[fields][67]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_67_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_67_1\">Oui<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_67_3\" name=\"wpforms[fields][67]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_67_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_67_3\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_68-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"68\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous une allergie ou une r\u00e9action \u00e0 l\u2019un des produits suivants? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_68\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-64-field_68_1\" name=\"wpforms[fields][68][]\" value=\"Latex\" aria-errormessage=\"wpforms-64-field_68_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_68_1\">Latex<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-64-field_68_2\" name=\"wpforms[fields][68][]\" value=\"P\u00e9nicilline\" aria-errormessage=\"wpforms-64-field_68_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_68_2\">P\u00e9nicilline<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-64-field_68_10\" name=\"wpforms[fields][68][]\" value=\"Autres antibiotiques\" aria-errormessage=\"wpforms-64-field_68_10-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_68_10\">Autres antibiotiques<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-64-field_68_9\" name=\"wpforms[fields][68][]\" value=\"Cod\u00e9ine\" aria-errormessage=\"wpforms-64-field_68_9-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_68_9\">Cod\u00e9ine<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-64-field_68_8\" name=\"wpforms[fields][68][]\" value=\"Aspirine\" aria-errormessage=\"wpforms-64-field_68_8-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_68_8\">Aspirine<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-64-field_68_7\" name=\"wpforms[fields][68][]\" value=\"Sulfamid\u00e9s\" aria-errormessage=\"wpforms-64-field_68_7-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_68_7\">Sulfamid\u00e9s<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-64-field_68_6\" name=\"wpforms[fields][68][]\" value=\"Anesth\u00e9siques\" aria-errormessage=\"wpforms-64-field_68_6-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_68_6\">Anesth\u00e9siques<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-64-field_68_5\" name=\"wpforms[fields][68][]\" value=\"Aliments\" aria-errormessage=\"wpforms-64-field_68_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_68_5\">Aliments<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-64-field_68_4\" name=\"wpforms[fields][68][]\" value=\"Produits contenant de l\u2019iode\" aria-errormessage=\"wpforms-64-field_68_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_68_4\">Produits contenant de l\u2019iode<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-64-field_68_12\" name=\"wpforms[fields][68][]\" value=\"Autre\" aria-errormessage=\"wpforms-64-field_68_12-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_68_12\">Autre<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-64-field_68_11\" name=\"wpforms[fields][68][]\" value=\"Aucune\" aria-errormessage=\"wpforms-64-field_68_11-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_68_11\">Aucune<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_69-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"69\"><label class=\"wpforms-field-label\" for=\"wpforms-64-field_69\">Si vous avez s\u00e9lectionn\u00e9 \u201cAutre\u201d, veuillez pr\u00e9ciser<\/label><input type=\"text\" id=\"wpforms-64-field_69\" class=\"wpforms-field-medium\" name=\"wpforms[fields][69]\" aria-errormessage=\"wpforms-64-field_69-error\" ><\/div><div id=\"wpforms-64-field_70-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"70\"><label class=\"wpforms-field-label\" for=\"wpforms-64-field_70\">Autres conditions m\u00e9dicales \u00e0 mentionner<\/label><textarea id=\"wpforms-64-field_70\" class=\"wpforms-field-medium\" name=\"wpforms[fields][70]\" aria-errormessage=\"wpforms-64-field_70-error\" ><\/textarea><\/div><div id=\"wpforms-64-field_77-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"77\"><fieldset><legend class=\"wpforms-field-label\">Vous a-t-on d\u00e9j\u00e0 dit que vous ronfliez ou que vous sembliez arr\u00eater de respirer pendant votre sommeil? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_77\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_77_1\" name=\"wpforms[fields][77]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_77_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_77_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_77_2\" name=\"wpforms[fields][77]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_77_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_77_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_78-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"78\"><fieldset><legend class=\"wpforms-field-label\">Vous r\u00e9veillez-vous fatigu\u00e9 le matin ou ressentez-vous de la fatigue durant la journ\u00e9e? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_78\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_78_1\" name=\"wpforms[fields][78]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_78_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_78_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_78_2\" name=\"wpforms[fields][78]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_78_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_78_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_79-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"79\"><fieldset><legend class=\"wpforms-field-label\">Souffrez-vous d\u2019apn\u00e9e du sommeil? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_79\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_79_1\" name=\"wpforms[fields][79]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_79_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_79_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_79_2\" name=\"wpforms[fields][79]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_79_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_79_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_80-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"80\"><fieldset><legend class=\"wpforms-field-label\">Fumez-vous? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_80\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_80_1\" name=\"wpforms[fields][80]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_80_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_80_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_80_2\" name=\"wpforms[fields][80]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_80_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_80_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_82-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"82\"><label class=\"wpforms-field-label\" for=\"wpforms-64-field_82\">Si vous fumez, combien de cigarettes par jour? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-64-field_82\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][82]\" step=\"any\" aria-errormessage=\"wpforms-64-field_82-error\" required><\/div><div id=\"wpforms-64-field_83-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"83\"><fieldset><legend class=\"wpforms-field-label\">Consommez-vous de l\u2019alcool? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_83\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_83_1\" name=\"wpforms[fields][83]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_83_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_83_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_83_2\" name=\"wpforms[fields][83]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_83_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_83_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_84-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"84\"><label class=\"wpforms-field-label\" for=\"wpforms-64-field_84\">Si oui, quelle est votre fr\u00e9quence de consommation?<\/label><input type=\"number\" id=\"wpforms-64-field_84\" class=\"wpforms-field-medium\" name=\"wpforms[fields][84]\" step=\"any\" aria-errormessage=\"wpforms-64-field_84-error\" ><\/div><div id=\"wpforms-64-field_85-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"85\"><fieldset><legend class=\"wpforms-field-label\">Consommez-vous du cannabis? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_85\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_85_1\" name=\"wpforms[fields][85]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_85_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_85_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_85_2\" name=\"wpforms[fields][85]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_85_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_85_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_86-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"86\"><fieldset><legend class=\"wpforms-field-label\">Consommez-vous d\u2019autres drogues? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_86\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_86_1\" name=\"wpforms[fields][86]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_86_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_86_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_86_2\" name=\"wpforms[fields][86]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_86_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_86_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-64-field_87-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"87\"><fieldset><legend class=\"wpforms-field-label\">Prenez-vous de la m\u00e9thadone? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_87\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_87_1\" name=\"wpforms[fields][87]\" value=\"Oui\" aria-errormessage=\"wpforms-64-field_87_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_87_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-64-field_87_2\" name=\"wpforms[fields][87]\" value=\"Non\" aria-errormessage=\"wpforms-64-field_87_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_87_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div>\t\t<div id=\"wpforms-64-field_81-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"81\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-64-field_81\" >en Avez-vous valvule<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-64-field_81\" class=\"wpforms-field-medium\" name=\"wpforms[fields][81]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-64-field_88-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"88\"><fieldset><legend class=\"wpforms-field-label\">Confirmation <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-64-field_88\" class=\"wpforms-field-required\"><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-64-field_88_2\" name=\"wpforms[fields][88][]\" value=\"Je confirme avoir rempli ce questionnaire m\u00e9dicodentaire au meilleur de ma connaissance.\" aria-errormessage=\"wpforms-64-field_88_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-64-field_88_2\">Je confirme avoir rempli ce questionnaire m\u00e9dicodentaire au meilleur de ma connaissance.<\/label><\/li><\/ul><\/fieldset><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-64-field_81-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-64-field_81-container input { visibility: hidden; } #wpforms-conversational-form-page #wpforms-64-field_81-container label { counter-increment: none; }' ) );\n\t\t\t\t\tdocument.head.appendChild( style );\n\t\t\t\t\tdocument.currentScript?.remove();\n\t\t\t\t} )();\n\t\t\t<\/script><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"64\"><input type=\"hidden\" name=\"wpforms[time_token]\" value=\"1789972234.66dda1ab9336435d52de04a143cd1b9fb996f86f971faa22645c2bea74839dfb\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/cliniquedentairesoleil-brossard.com\/en\/wp-json\/wp\/v2\/pages\/76\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-64\" class=\"wpforms-submit\" data-alt-text=\"Envoi en cours...\" data-submit-text=\"Soumettre\" aria-live=\"assertive\" value=\"wpforms-submit\">Soumettre<\/button><img decoding=\"async\" src=\"https:\/\/cliniquedentairesoleil-brossard.com\/wp-content\/plugins\/wpforms-lite\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Nouveaux patients Questionnaire m\u00e9dical Afin de pr\u00e9parer votre visite, veuillez remplir ce questionnaire au meilleur de votre connaissance. Ces renseignements nous aident \u00e0 vous offrir des soins s\u00e9curitaires et adapt\u00e9s \u00e0 votre situation. Avant de commencer Veuillez pr\u00e9voir quelques minutes pour compl\u00e9ter le formulaire. Si votre \u00e9tat de sant\u00e9 change, informez notre \u00e9quipe lors de [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-76","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/cliniquedentairesoleil-brossard.com\/en\/wp-json\/wp\/v2\/pages\/76","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/cliniquedentairesoleil-brossard.com\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/cliniquedentairesoleil-brossard.com\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/cliniquedentairesoleil-brossard.com\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/cliniquedentairesoleil-brossard.com\/en\/wp-json\/wp\/v2\/comments?post=76"}],"version-history":[{"count":11,"href":"https:\/\/cliniquedentairesoleil-brossard.com\/en\/wp-json\/wp\/v2\/pages\/76\/revisions"}],"predecessor-version":[{"id":91,"href":"https:\/\/cliniquedentairesoleil-brossard.com\/en\/wp-json\/wp\/v2\/pages\/76\/revisions\/91"}],"wp:attachment":[{"href":"https:\/\/cliniquedentairesoleil-brossard.com\/en\/wp-json\/wp\/v2\/media?parent=76"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}