{"id":363,"date":"2026-10-28T07:30:36","date_gmt":"2026-10-28T12:30:36","guid":{"rendered":"https:\/\/keeganmcconnell.com\/physiteam\/?page_id=363"},"modified":"2026-10-28T13:05:11","modified_gmt":"2026-10-28T18:05:11","slug":"health-quiz","status":"publish","type":"page","link":"https:\/\/keeganmcconnell.com\/physiteam\/health-quiz\/","title":{"rendered":"Health Quiz"},"content":{"rendered":"<div class=\"wpb-content-wrapper\" id=\"wpb-content-root\"><p>[vc_row gap=&#8221;30px&#8221; content_placement=&#8221;middle&#8221;][vc_column width=&#8221;1\/4&#8243;]<div class=\"ult-spacer spacer-6af0e1663cbc7\" data-id=\"6af0e1663cbc7\" data-height=\"20\" data-height-mobile=\"20\" data-height-tab=\"20\" data-height-tab-portrait=\"\" data-height-mobile-landscape=\"\" style=\"clear:both;display:block;\"><\/div>[\/vc_column][vc_column width=&#8221;1\/2&#8243;][vc_column_text]<div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_2_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form \" id=\"form_health-quiz\" data-frm-error-config=\"{&quot;includeAlertRole&quot;:false,&quot;focusFirstError&quot;:false,&quot;focusErrorSummary&quot;:true}\" >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Health Quiz<\/legend>\r\n\r\n<div class=\"frm_description\"><p>The Health Quiz is not diagnostic but serves as a baseline and progress-tracking tool.<\/p>\n<p>It identifies symptoms that help to identify the underlying causes of decreased performance or illness, and helps you track your progress over time.<\/p>\n<h2>How to Complete<\/h2>\n<p>INSTRUCTIONS<br \/>\n* Rate each of the following symptoms based upon your health profile and symptoms for the last 48 hours ONLY using the POINT SCALE below.<br \/>\n* Select ONLY ONE response for each category.<br \/>\n* A response is required for each category to complete submission of the form.<br \/>\n* If you are unable to submit your quiz, please review your responses for \"required\" categories.<br \/>\nPOINT SCALE<br \/>\n0 = Never or almost never have the symptom<br \/>\n1 = Occasionally have it, effect is not severe<br \/>\n2 = Occasionally have it, effect is severe<br \/>\n3 = Frequently have it, effect is not severe<br \/>\n4 = Frequently have it, effect is severe<\/p>\n<\/div><div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"2\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_2\" id=\"frm_hide_fields_2\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"health-quiz\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_2\" name=\"frm_submit_entry_2\" value=\"f4007a7160\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/physiteam\/wp-json\/wp\/v2\/pages\/363\" \/><div id=\"frm_field_9_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_6dt1b2\" id=\"field_6dt1b2_label\" class=\"frm_primary_label\">Name\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_6dt1b2\" name=\"item_meta[9]\" value=\"\"  data-reqmsg=\"Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Name is invalid\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_10_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n\t<label for=\"field_29yf4d2\" id=\"field_29yf4d2_label\" class=\"frm_primary_label\">Email\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"email\" id=\"field_29yf4d2\" name=\"item_meta[10]\" value=\"\"  data-reqmsg=\"Email cannot be blank.\" aria-required=\"true\" data-invmsg=\"Please enter a valid email address\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_11_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_9yaia2\" id=\"field_9yaia2_label\" class=\"frm_primary_label\">Phone\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_9yaia2\" name=\"item_meta[11]\" value=\"\"  data-reqmsg=\"Phone cannot be blank.\" aria-required=\"true\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_14_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_ks2ie\" id=\"field_ks2ie_label\" class=\"frm_primary_label\">Nausea or vomiting\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[14]\" id=\"field_ks2ie\"  data-reqmsg=\"Nausea or vomiting cannot be blank.\" aria-required=\"true\" data-invmsg=\"Nausea or vomiting is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_16_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_tibft\" id=\"field_tibft_label\" class=\"frm_primary_label\">Diarrhea\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[16]\" id=\"field_tibft\"  data-reqmsg=\"Diarrhea cannot be blank.\" aria-required=\"true\" data-invmsg=\"Diarrhea is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_15_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_a0wma\" id=\"field_a0wma_label\" class=\"frm_primary_label\">Constipation\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[15]\" id=\"field_a0wma\"  data-reqmsg=\"Constipation cannot be blank.\" aria-required=\"true\" data-invmsg=\"Constipation is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_17_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_rbssp\" id=\"field_rbssp_label\" class=\"frm_primary_label\">Bloated feeling\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[17]\" id=\"field_rbssp\"  data-reqmsg=\"Bloated feeling cannot be blank.\" aria-required=\"true\" data-invmsg=\"Bloated feeling is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_18_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_okwwy\" id=\"field_okwwy_label\" class=\"frm_primary_label\">Belching or passing gas\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[18]\" id=\"field_okwwy\"  data-reqmsg=\"Belching or passing gas cannot be blank.\" aria-required=\"true\" data-invmsg=\"Belching or passing gas is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_19_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_ex0n2\" id=\"field_ex0n2_label\" class=\"frm_primary_label\">Heartburn\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[19]\" id=\"field_ex0n2\"  data-reqmsg=\"Heartburn cannot be blank.\" aria-required=\"true\" data-invmsg=\"Heartburn is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_20_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_kotti\" id=\"field_kotti_label\" class=\"frm_primary_label\">Intestinal\/stomach pain\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[20]\" id=\"field_kotti\"  data-reqmsg=\"Intestinal\/stomach pain cannot be blank.\" aria-required=\"true\" data-invmsg=\"Intestinal\/stomach pain is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_21_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_30p4\" id=\"field_30p4_label\" class=\"frm_primary_label\">Itchy ears\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[21]\" id=\"field_30p4\"  data-reqmsg=\"Itchy ears cannot be blank.\" aria-required=\"true\" data-invmsg=\"Itchy ears is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_22_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_ikda6\" id=\"field_ikda6_label\" class=\"frm_primary_label\">Earaches, ear infections\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[22]\" id=\"field_ikda6\"  data-reqmsg=\"Earaches, ear infections cannot be blank.\" aria-required=\"true\" data-invmsg=\"Earaches, ear infections is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_23_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_bsrgp\" id=\"field_bsrgp_label\" class=\"frm_primary_label\">Drainage from ear\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[23]\" id=\"field_bsrgp\"  data-reqmsg=\"Drainage from ear cannot be blank.\" aria-required=\"true\" data-invmsg=\"Drainage from ear is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_24_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_iqiog\" id=\"field_iqiog_label\" class=\"frm_primary_label\">Ringing in ears, hearing loss\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[24]\" id=\"field_iqiog\"  data-reqmsg=\"Ringing in ears, hearing loss cannot be blank.\" aria-required=\"true\" data-invmsg=\"Ringing in ears, hearing loss is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_25_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_7mtrl\" id=\"field_7mtrl_label\" class=\"frm_primary_label\">Mood swings\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[25]\" id=\"field_7mtrl\"  data-reqmsg=\"Mood swings cannot be blank.\" aria-required=\"true\" data-invmsg=\"Mood swings is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_26_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_1grdy\" id=\"field_1grdy_label\" class=\"frm_primary_label\">Anxiety, fear or nervousness\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[26]\" id=\"field_1grdy\"  data-reqmsg=\"Anxiety, fear or nervousness cannot be blank.\" aria-required=\"true\" data-invmsg=\"Anxiety, fear or nervousness is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_27_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_f8p08\" id=\"field_f8p08_label\" class=\"frm_primary_label\">Anger, irritability, or aggressiveness\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[27]\" id=\"field_f8p08\"  data-reqmsg=\"Anger, irritability, or aggressiveness cannot be blank.\" aria-required=\"true\" data-invmsg=\"Anger, irritability, or aggressiveness is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_28_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_8k5ca\" id=\"field_8k5ca_label\" class=\"frm_primary_label\">Depression\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[28]\" id=\"field_8k5ca\"  data-reqmsg=\"Depression cannot be blank.\" aria-required=\"true\" data-invmsg=\"Depression is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_29_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_sziyv\" id=\"field_sziyv_label\" class=\"frm_primary_label\">Fatigue, sluggishness\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[29]\" id=\"field_sziyv\"  data-reqmsg=\"Fatigue, sluggishness cannot be blank.\" aria-required=\"true\" data-invmsg=\"Fatigue, sluggishness is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_30_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_d5a9v\" id=\"field_d5a9v_label\" class=\"frm_primary_label\">Apathy, lethargy\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[30]\" id=\"field_d5a9v\"  data-reqmsg=\"Apathy, lethargy cannot be blank.\" aria-required=\"true\" data-invmsg=\"Apathy, lethargy is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_31_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_p39ly\" id=\"field_p39ly_label\" class=\"frm_primary_label\">Hyperactivity\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[31]\" id=\"field_p39ly\"  data-reqmsg=\"Hyperactivity cannot be blank.\" aria-required=\"true\" data-invmsg=\"Hyperactivity is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_32_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_xmwlb\" id=\"field_xmwlb_label\" class=\"frm_primary_label\">Restlessness\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[32]\" id=\"field_xmwlb\"  data-reqmsg=\"Restlessness cannot be blank.\" aria-required=\"true\" data-invmsg=\"Restlessness is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_33_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_bfr21\" id=\"field_bfr21_label\" class=\"frm_primary_label\">Watery or itchy eyes\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[33]\" id=\"field_bfr21\"  data-reqmsg=\"Watery or itchy eyes cannot be blank.\" aria-required=\"true\" data-invmsg=\"Watery or itchy eyes is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_34_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_xlxl9\" id=\"field_xlxl9_label\" class=\"frm_primary_label\">Swollen, reddened or sticky eyelids\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[34]\" id=\"field_xlxl9\"  data-reqmsg=\"Swollen, reddened or sticky eyelids cannot be blank.\" aria-required=\"true\" data-invmsg=\"Swollen, reddened or sticky eyelids is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_35_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_xsbmq\" id=\"field_xsbmq_label\" class=\"frm_primary_label\">Bags or dark circles under eyes\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[35]\" id=\"field_xsbmq\"  data-reqmsg=\"Bags or dark circles under eyes cannot be blank.\" aria-required=\"true\" data-invmsg=\"Bags or dark circles under eyes is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_36_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_wx5h9\" id=\"field_wx5h9_label\" class=\"frm_primary_label\">Blurred or tunnel vision (does not include near- or far-sightedness)\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[36]\" id=\"field_wx5h9\"  data-reqmsg=\"Blurred or tunnel vision (does not include near- or far-sightedness) cannot be blank.\" aria-required=\"true\" data-invmsg=\"Blurred or tunnel vision (does not include near- or far-sightedness) is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_37_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_3geg6\" id=\"field_3geg6_label\" class=\"frm_primary_label\">Headaches\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[37]\" id=\"field_3geg6\"  data-reqmsg=\"Headaches cannot be blank.\" aria-required=\"true\" data-invmsg=\"Headaches is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_38_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_pdy7r\" id=\"field_pdy7r_label\" class=\"frm_primary_label\">Faintness\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[38]\" id=\"field_pdy7r\"  data-reqmsg=\"Faintness cannot be blank.\" aria-required=\"true\" data-invmsg=\"Faintness is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_39_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_215zs\" id=\"field_215zs_label\" class=\"frm_primary_label\">Dizziness\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[39]\" id=\"field_215zs\"  data-reqmsg=\"Dizziness cannot be blank.\" aria-required=\"true\" data-invmsg=\"Dizziness is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_40_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_nw7yx\" id=\"field_nw7yx_label\" class=\"frm_primary_label\">Insomnia\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[40]\" id=\"field_nw7yx\"  data-reqmsg=\"Insomnia cannot be blank.\" aria-required=\"true\" data-invmsg=\"Insomnia is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_41_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_2jvb\" id=\"field_2jvb_label\" class=\"frm_primary_label\">Irregular or skipped heartbeat\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[41]\" id=\"field_2jvb\"  data-reqmsg=\"Irregular or skipped heartbeat cannot be blank.\" aria-required=\"true\" data-invmsg=\"Irregular or skipped heartbeat is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_42_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_7ylti\" id=\"field_7ylti_label\" class=\"frm_primary_label\">Rapid or pounding heartbeat\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[42]\" id=\"field_7ylti\"  data-reqmsg=\"Rapid or pounding heartbeat cannot be blank.\" aria-required=\"true\" data-invmsg=\"Rapid or pounding heartbeat is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_43_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_z8ms2\" id=\"field_z8ms2_label\" class=\"frm_primary_label\">Chest pain\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[43]\" id=\"field_z8ms2\"  data-reqmsg=\"Chest pain cannot be blank.\" aria-required=\"true\" data-invmsg=\"Chest pain is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_44_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_xgjow\" id=\"field_xgjow_label\" class=\"frm_primary_label\">Pain or aches in joints\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[44]\" id=\"field_xgjow\"  data-reqmsg=\"Pain or aches in joints cannot be blank.\" aria-required=\"true\" data-invmsg=\"Pain or aches in joints is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_45_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_7dq4q\" id=\"field_7dq4q_label\" class=\"frm_primary_label\">Arthritis\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[45]\" id=\"field_7dq4q\"  data-reqmsg=\"Arthritis cannot be blank.\" aria-required=\"true\" data-invmsg=\"Arthritis is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_46_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_ft5ro\" id=\"field_ft5ro_label\" class=\"frm_primary_label\">Stiffness or limitation in movement\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[46]\" id=\"field_ft5ro\"  data-reqmsg=\"Stiffness or limitation in movement cannot be blank.\" aria-required=\"true\" data-invmsg=\"Stiffness or limitation in movement is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_47_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_nzz78\" id=\"field_nzz78_label\" class=\"frm_primary_label\">Pain or aches in muscles\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[47]\" id=\"field_nzz78\"  data-reqmsg=\"Pain or aches in muscles cannot be blank.\" aria-required=\"true\" data-invmsg=\"Pain or aches in muscles is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_48_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_2k2d3\" id=\"field_2k2d3_label\" class=\"frm_primary_label\">Feeling of weakness or tiredness\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[48]\" id=\"field_2k2d3\"  data-reqmsg=\"Feeling of weakness or tiredness cannot be blank.\" aria-required=\"true\" data-invmsg=\"Feeling of weakness or tiredness is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_49_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_17ujd\" id=\"field_17ujd_label\" class=\"frm_primary_label\">Chest congestion\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[49]\" id=\"field_17ujd\"  data-reqmsg=\"Chest congestion cannot be blank.\" aria-required=\"true\" data-invmsg=\"Chest congestion is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_50_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_g480q\" id=\"field_g480q_label\" class=\"frm_primary_label\">Asthma, bronchitis\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[50]\" id=\"field_g480q\"  data-reqmsg=\"Asthma, bronchitis cannot be blank.\" aria-required=\"true\" data-invmsg=\"Asthma, bronchitis is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_51_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_mvlnk\" id=\"field_mvlnk_label\" class=\"frm_primary_label\">Shortness of breath\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[51]\" id=\"field_mvlnk\"  data-reqmsg=\"Shortness of breath cannot be blank.\" aria-required=\"true\" data-invmsg=\"Shortness of breath is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_54_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_db3ct\" id=\"field_db3ct_label\" class=\"frm_primary_label\">Difficult breathing\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[54]\" id=\"field_db3ct\"  data-reqmsg=\"Difficult breathing cannot be blank.\" aria-required=\"true\" data-invmsg=\"Difficult breathing is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_53_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_5ljf5\" id=\"field_5ljf5_label\" class=\"frm_primary_label\">Poor memory\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[53]\" id=\"field_5ljf5\"  data-reqmsg=\"Poor memory cannot be blank.\" aria-required=\"true\" data-invmsg=\"Poor memory is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_52_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_94z4k\" id=\"field_94z4k_label\" class=\"frm_primary_label\">Confusion, poor comprehension\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[52]\" id=\"field_94z4k\"  data-reqmsg=\"Confusion, poor comprehension cannot be blank.\" aria-required=\"true\" data-invmsg=\"Confusion, poor comprehension is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_55_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_op3np\" id=\"field_op3np_label\" class=\"frm_primary_label\">Poor concentration\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[55]\" id=\"field_op3np\"  data-reqmsg=\"Poor concentration cannot be blank.\" aria-required=\"true\" data-invmsg=\"Poor concentration is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_56_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_27py5\" id=\"field_27py5_label\" class=\"frm_primary_label\">Poor physical coordination\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[56]\" id=\"field_27py5\"  data-reqmsg=\"Poor physical coordination cannot be blank.\" aria-required=\"true\" data-invmsg=\"Poor physical coordination is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_57_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_hcq64\" id=\"field_hcq64_label\" class=\"frm_primary_label\">Difficulty in making decisions\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[57]\" id=\"field_hcq64\"  data-reqmsg=\"Difficulty in making decisions cannot be blank.\" aria-required=\"true\" data-invmsg=\"Difficulty in making decisions is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_58_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_ombp\" id=\"field_ombp_label\" class=\"frm_primary_label\">Stuttering or stammering\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[58]\" id=\"field_ombp\"  data-reqmsg=\"Stuttering or stammering cannot be blank.\" aria-required=\"true\" data-invmsg=\"Stuttering or stammering is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_59_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_x0kb4\" id=\"field_x0kb4_label\" class=\"frm_primary_label\">Slurred speech\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[59]\" id=\"field_x0kb4\"  data-reqmsg=\"Slurred speech cannot be blank.\" aria-required=\"true\" data-invmsg=\"Slurred speech is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_60_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_a512q\" id=\"field_a512q_label\" class=\"frm_primary_label\">Learning disabilities\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[60]\" id=\"field_a512q\"  data-reqmsg=\"Learning disabilities cannot be blank.\" aria-required=\"true\" data-invmsg=\"Learning disabilities is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_61_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_exfn9\" id=\"field_exfn9_label\" class=\"frm_primary_label\">Chronic coughing\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[61]\" id=\"field_exfn9\"  data-reqmsg=\"Chronic coughing cannot be blank.\" aria-required=\"true\" data-invmsg=\"Chronic coughing is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_62_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_o1uqr\" id=\"field_o1uqr_label\" class=\"frm_primary_label\">Gagging, frequent need to clear throat\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[62]\" id=\"field_o1uqr\"  data-reqmsg=\"Gagging, frequent need to clear throat cannot be blank.\" aria-required=\"true\" data-invmsg=\"Gagging, frequent need to clear throat is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_63_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_ko0s\" id=\"field_ko0s_label\" class=\"frm_primary_label\">Sore throat, hoarseness, loss of voice\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[63]\" id=\"field_ko0s\"  data-reqmsg=\"Sore throat, hoarseness, loss of voice cannot be blank.\" aria-required=\"true\" data-invmsg=\"Sore throat, hoarseness, loss of voice is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_64_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_yrc80\" id=\"field_yrc80_label\" class=\"frm_primary_label\">Swollen\/discolored tongue, gums, lips\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[64]\" id=\"field_yrc80\"  data-reqmsg=\"Swollen\/discolored tongue, gums, lips cannot be blank.\" aria-required=\"true\" data-invmsg=\"Swollen\/discolored tongue, gums, lips is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_65_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_ntkum\" id=\"field_ntkum_label\" class=\"frm_primary_label\">Canker sores\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[65]\" id=\"field_ntkum\"  data-reqmsg=\"Canker sores cannot be blank.\" aria-required=\"true\" data-invmsg=\"Canker sores is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_66_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_1p4a7\" id=\"field_1p4a7_label\" class=\"frm_primary_label\">Stuffy nose\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[66]\" id=\"field_1p4a7\"  data-reqmsg=\"Stuffy nose cannot be blank.\" aria-required=\"true\" data-invmsg=\"Stuffy nose is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_67_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_a3xcr\" id=\"field_a3xcr_label\" class=\"frm_primary_label\">Sinus problems\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[67]\" id=\"field_a3xcr\"  data-reqmsg=\"Sinus problems cannot be blank.\" aria-required=\"true\" data-invmsg=\"Sinus problems is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_68_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_pt3vs\" id=\"field_pt3vs_label\" class=\"frm_primary_label\">Hay fever\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[68]\" id=\"field_pt3vs\"  data-reqmsg=\"Hay fever cannot be blank.\" aria-required=\"true\" data-invmsg=\"Hay fever is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_69_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_tuggf\" id=\"field_tuggf_label\" class=\"frm_primary_label\">Sneezing attacks\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[69]\" id=\"field_tuggf\"  data-reqmsg=\"Sneezing attacks cannot be blank.\" aria-required=\"true\" data-invmsg=\"Sneezing attacks is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_70_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_3mi5t\" id=\"field_3mi5t_label\" class=\"frm_primary_label\">Excessive mucus formation\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[70]\" id=\"field_3mi5t\"  data-reqmsg=\"Excessive mucus formation cannot be blank.\" aria-required=\"true\" data-invmsg=\"Excessive mucus formation is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_71_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_ku48o\" id=\"field_ku48o_label\" class=\"frm_primary_label\">Acne\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[71]\" id=\"field_ku48o\"  data-reqmsg=\"Acne cannot be blank.\" aria-required=\"true\" data-invmsg=\"Acne is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_72_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_edo84\" id=\"field_edo84_label\" class=\"frm_primary_label\">Hives, rashes, or dry skin\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[72]\" id=\"field_edo84\"  data-reqmsg=\"Hives, rashes, or dry skin cannot be blank.\" aria-required=\"true\" data-invmsg=\"Hives, rashes, or dry skin is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_73_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_ak4qr\" id=\"field_ak4qr_label\" class=\"frm_primary_label\">Hair loss\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[73]\" id=\"field_ak4qr\"  data-reqmsg=\"Hair loss cannot be blank.\" aria-required=\"true\" data-invmsg=\"Hair loss is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_74_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_aah0v\" id=\"field_aah0v_label\" class=\"frm_primary_label\">Skin flushes or hot flushes\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[74]\" id=\"field_aah0v\"  data-reqmsg=\"Skin flushes or hot flushes cannot be blank.\" aria-required=\"true\" data-invmsg=\"Skin flushes or hot flushes is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_75_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_moea1\" id=\"field_moea1_label\" class=\"frm_primary_label\">Excessive sweating\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[75]\" id=\"field_moea1\"  data-reqmsg=\"Excessive sweating cannot be blank.\" aria-required=\"true\" data-invmsg=\"Excessive sweating is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_76_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_wx1ba\" id=\"field_wx1ba_label\" class=\"frm_primary_label\">Binge eating\/drinking\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[76]\" id=\"field_wx1ba\"  data-reqmsg=\"Binge eating\/drinking cannot be blank.\" aria-required=\"true\" data-invmsg=\"Binge eating\/drinking is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_77_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_who1e\" id=\"field_who1e_label\" class=\"frm_primary_label\">Craving certain foods\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[77]\" id=\"field_who1e\"  data-reqmsg=\"Craving certain foods cannot be blank.\" aria-required=\"true\" data-invmsg=\"Craving certain foods is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_78_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_ar44v\" id=\"field_ar44v_label\" class=\"frm_primary_label\">Excessive weight\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[78]\" id=\"field_ar44v\"  data-reqmsg=\"Excessive weight cannot be blank.\" aria-required=\"true\" data-invmsg=\"Excessive weight is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_79_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_hnifa\" id=\"field_hnifa_label\" class=\"frm_primary_label\">Compulsive eating\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[79]\" id=\"field_hnifa\"  data-reqmsg=\"Compulsive eating cannot be blank.\" aria-required=\"true\" data-invmsg=\"Compulsive eating is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_80_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_zcw8g\" id=\"field_zcw8g_label\" class=\"frm_primary_label\">Water retention\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[80]\" id=\"field_zcw8g\"  data-reqmsg=\"Water retention cannot be blank.\" aria-required=\"true\" data-invmsg=\"Water retention is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_81_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_gutyz\" id=\"field_gutyz_label\" class=\"frm_primary_label\">Underweight\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[81]\" id=\"field_gutyz\"  data-reqmsg=\"Underweight cannot be blank.\" aria-required=\"true\" data-invmsg=\"Underweight is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_82_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_7qb9w\" id=\"field_7qb9w_label\" class=\"frm_primary_label\">Frequent illness\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[82]\" id=\"field_7qb9w\"  data-reqmsg=\"Frequent illness cannot be blank.\" aria-required=\"true\" data-invmsg=\"Frequent illness is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_83_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_zj5zw\" id=\"field_zj5zw_label\" class=\"frm_primary_label\">Frequent or urgent urination\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[83]\" id=\"field_zj5zw\"  data-reqmsg=\"Frequent or urgent urination cannot be blank.\" aria-required=\"true\" data-invmsg=\"Frequent or urgent urination is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_84_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_kzse3\" id=\"field_kzse3_label\" class=\"frm_primary_label\">Genital itch or discharge\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[84]\" id=\"field_kzse3\"  data-reqmsg=\"Genital itch or discharge cannot be blank.\" aria-required=\"true\" data-invmsg=\"Genital itch or discharge is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"0 = Never or almost never have the symptom\">0 = Never or almost never have the symptom<\/option><option  value=\"1 = Occasionally have it, effect is not severe\">1 = Occasionally have it, effect is not severe<\/option><option  value=\"2 = Occasionally have, effect is severe\">2 = Occasionally have, effect is severe<\/option><option  value=\"3 = Frequently have it, effect is not severe\">3 = Frequently have it, effect is not severe<\/option><option  value=\"4 = Frequently have it, effect is severe\">4 = Frequently have it, effect is severe<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_85_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_kpogj\" id=\"field_kpogj_label\" class=\"frm_primary_label\">I'm interested in speaking with a team member about my results for a more in-depth analysis.\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[85]\" id=\"field_kpogj\"  data-reqmsg=\"I&#039;m interested in speaking with a team member about my results for a more in-depth analysis. cannot be blank.\" aria-required=\"true\" data-invmsg=\"I&#039;m interested in speaking with a team member about my results for a more in-depth analysis. is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"Yes, that would be great!\">Yes, that would be great!<\/option><option  value=\"Not at this time.\">Not at this time.<\/option><option  value=\"I&#039;m not sure.\">I&#039;m not sure.<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_13_container\" class=\"frm_form_field form-field \">\r\n\t<div class=\"frm_submit frm_flex\">\r\n<button class=\"frm_button_submit\" type=\"submit\"  >Submit<\/button>\r\n\r\n\r\n\r\n<\/div>\r\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t<div id=\"frm_field_86_container\">\n\t\t\t<label for=\"field_6odhv\" >\n\t\t\t\tIf you are human, leave this field blank.\t\t\t<\/label>\n\t\t\t<input  id=\"field_6odhv\" type=\"text\" class=\"frm_form_field form-field frm_verify\" name=\"item_meta[86]\" value=\"\"  \/>\n\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"5x8DL3Tq30bc8vWUqd1pqXYqu3Jc9pQZ5NFPsjmm5iQ=\" \/><\/div>\n<\/fieldset>\n<\/div>\n\n<\/form>\n<\/div>\n[\/vc_column_text][\/vc_column][vc_column width=&#8221;1\/4&#8243;]<div class=\"ult-spacer spacer-6af0e16686dda\" data-id=\"6af0e16686dda\" data-height=\"20\" data-height-mobile=\"20\" data-height-tab=\"20\" data-height-tab-portrait=\"\" data-height-mobile-landscape=\"\" 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