{"id":817,"date":"2017-07-03T16:05:54","date_gmt":"2017-07-03T16:05:54","guid":{"rendered":"http:\/\/www.rocklandortho.ca\/?page_id=817\/"},"modified":"2017-07-03T16:05:54","modified_gmt":"2017-07-03T16:05:54","slug":"consultation-questionnaire","status":"publish","type":"page","link":"https:\/\/www.rocklandortho.ca\/fr\/consultation-questionnaire\/","title":{"rendered":"Consultation questionnaire"},"content":{"rendered":"[vc_row type=\u00a0\u00bbin_container\u00a0\u00bb full_screen_row_position=\u00a0\u00bbmiddle\u00a0\u00bb scene_position=\u00a0\u00bbcenter\u00a0\u00bb text_color=\u00a0\u00bbdark\u00a0\u00bb text_align=\u00a0\u00bbleft\u00a0\u00bb overlay_strength=\u00a0\u00bb0.3&Prime;][vc_column column_padding=\u00a0\u00bbno-extra-padding\u00a0\u00bb column_padding_position=\u00a0\u00bball\u00a0\u00bb background_color_opacity=\u00a0\u00bb1&Prime; background_hover_color_opacity=\u00a0\u00bb1&Prime; column_shadow=\u00a0\u00bbnone\u00a0\u00bb width=\u00a0\u00bb1\/1&Prime; tablet_text_alignment=\u00a0\u00bbdefault\u00a0\u00bb phone_text_alignment=\u00a0\u00bbdefault\u00a0\u00bb column_border_width=\u00a0\u00bbnone\u00a0\u00bb column_border_style=\u00a0\u00bbsolid\u00a0\u00bb]<script type=\"text\/javascript\">if(!gform){document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0});var gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),null==t&&(t=10),gform.hooks[o][n].push({tag:i,callable:r,priority:t})},doHook:function(o,n,r){if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[o][n]){var t,i=gform.hooks[o][n];i.sort(function(o,n){return o.priority-n.priority});for(var e=0;e<i.length;e++)\"function\"!=typeof(t=i[e].callable)&&(t=window[t]),\"action\"==o?t.apply(null,r):r[0]=t.apply(null,r)}if(\"filter\"==o)return r[0]},removeHook:function(o,n,r,t){if(null!=gform.hooks[o][n])for(var i=gform.hooks[o][n],e=i.length-1;0<=e;e--)null!=t&&t!=i[e].tag||null!=r&&r!=i[e].priority||i.splice(e,1)}}}<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper' id='gform_wrapper_6' ><form method='post' enctype='multipart\/form-data'  id='gform_6'  action='\/fr\/wp-json\/wp\/v2\/pages\/817\/' >\n                        <div class='gform_body gform-body'><ul id='gform_fields_6' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_6_1\" class=\"gfield gsection formtitle field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Patient<\/h2><\/li><li id=\"field_6_2\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_6_2'>\n                            \n                            <span id='input_6_2_3_container' class='name_first' >\n                                                    <input type='text' name='input_2.3' id='input_6_2_3' value='' aria-label='Pr\u00e9nom'   aria-required='true'     \/>\n                                                    <label for='input_6_2_3' >Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_6_2_6_container' class='name_last' >\n                                                    <input type='text' name='input_2.6' id='input_6_2_6' value='' aria-label='Nom'   aria-required='true'     \/>\n                                                    <label for='input_6_2_6' >Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_6_3\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label screen-reader-text gfield_label_before_complex'  ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_3'><li class='gchoice gchoice_6_3_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.1' type='checkbox'  value='M'  id='choice_6_3_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_3_1' id='label_6_3_1'>M<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_3_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.2' type='checkbox'  value='F'  id='choice_6_3_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_3_2' id='label_6_3_2'>F<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_4\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_6_4' >DDN (AAAA\/MM\/JJ)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_4' id='input_6_4' type='text' value='' class='datepicker ymd_slash datepicker_with_icon gdatepicker_with_icon'   placeholder='jj\/mm\/aaaa' aria-describedby=\"input_6_4_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_4_date_format' class='screen-reader-text'>AAAA slash MM slash JJ<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_4' class='gform_hidden' value='https:\/\/www.rocklandortho.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_6_5\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Addresse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_6_5' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_6_5_1_container' >\n                                        <input type='text' name='input_5.1' id='input_6_5_1' value=''    aria-required='true'    \/>\n                                        <label for='input_6_5_1' id='input_6_5_1_label' >No. civique<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_6_5_2_container' >\n                                        <input type='text' name='input_5.2' id='input_6_5_2' value=''     aria-required='false'   \/>\n                                        <label for='input_6_5_2' id='input_6_5_2_label' >Adresse ligne 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_6_5_3_container' >\n                                    <input type='text' name='input_5.3' id='input_6_5_3' value=''    aria-required='true'    \/>\n                                    <label for='input_6_5_3' id='input_6_5_3_label' >Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_6_5_4_container' >\n                                        <select name='input_5.4' id='input_6_5_4'     aria-required='true'    ><option value='' ><\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Terre-Neuve-et-Labrador' >Terre-Neuve-et-Labrador<\/option><option value='Territoires du Nord-Ouest' >Territoires du Nord-Ouest<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='\u00cele du Prince-\u00c9douard' >\u00cele du Prince-\u00c9douard<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_6_5_4' id='input_6_5_4_label' >Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_6_5_5_container' >\n                                    <input type='text' name='input_5.5' id='input_6_5_5' value=''    aria-required='true'    \/>\n                                    <label for='input_6_5_5' id='input_6_5_5_label' >Code postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_5.6' id='input_6_5_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_6_6\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_6_6' >T\u00e9l\u00e9phone R\u00e9s.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_6_6' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_21\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_6_21' >T\u00e9l\u00e9phone  Bur.\/Cell.<\/label><div class='ginput_container ginput_container_phone'><input name='input_21' id='input_6_21' type='text' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_8\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_6_8' >Courriel<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_8' id='input_6_8' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_6_9\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >\u00c9tat civil<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_9'><li class='gchoice gchoice_6_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.1' type='checkbox'  value='C\u00e9libataire'  id='choice_6_9_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_9_1' id='label_6_9_1'>C\u00e9libataire<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_9_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.2' type='checkbox'  value='En couple'  id='choice_6_9_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_9_2' id='label_6_9_2'>En couple<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_9_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.3' type='checkbox'  value='Mari\u00e9'  id='choice_6_9_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_9_3' id='label_6_9_3'>Mari\u00e9<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_9_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.4' type='checkbox'  value='S\u00e9par\u00e9\/Divorc\u00e9'  id='choice_6_9_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_9_4' id='label_6_9_4'>S\u00e9par\u00e9\/Divorc\u00e9<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_10\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_6_10' >Dentiste du patient<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_6_10' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_11\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_6_11' >Date du dernier examen dentaire<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_6_11' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_13\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_6_13' >M\u00e9decin du patient<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_6_13' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_12\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_6_12' >Date du dernier examen m\u00e9dical<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_6_12' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_14\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_6_14' >Patient r\u00e9f\u00e9r\u00e9 par<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_6_14' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_15\" class=\"gfield gsection formtitle field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Responsable(s)<\/h2><\/li><li id=\"field_6_16\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_6_16'>\n                            \n                            <span id='input_6_16_3_container' class='name_first' >\n                                                    <input type='text' name='input_16.3' id='input_6_16_3' value='' aria-label='Pr\u00e9nom'   aria-required='true'     \/>\n                                                    <label for='input_6_16_3' >Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_6_16_6_container' class='name_last' >\n                                                    <input type='text' name='input_16.6' id='input_6_16_6' value='' aria-label='Nom'   aria-required='true'     \/>\n                                                    <label for='input_6_16_6' >Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_6_17\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_6_17' >Relation avec le patient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_6_17' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_18\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Addresse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_6_18' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_6_18_1_container' >\n                                        <input type='text' name='input_18.1' id='input_6_18_1' value=''    aria-required='true'    \/>\n                                        <label for='input_6_18_1' id='input_6_18_1_label' >No. civique<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_6_18_2_container' >\n                                        <input type='text' name='input_18.2' id='input_6_18_2' value=''     aria-required='false'   \/>\n                                        <label for='input_6_18_2' id='input_6_18_2_label' >Adresse ligne 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_6_18_3_container' >\n                                    <input type='text' name='input_18.3' id='input_6_18_3' value=''    aria-required='true'    \/>\n                                    <label for='input_6_18_3' id='input_6_18_3_label' >Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_6_18_4_container' >\n                                        <select name='input_18.4' id='input_6_18_4'     aria-required='true'    ><option value='' ><\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Terre-Neuve-et-Labrador' >Terre-Neuve-et-Labrador<\/option><option value='Territoires du Nord-Ouest' >Territoires du Nord-Ouest<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='\u00cele du Prince-\u00c9douard' >\u00cele du Prince-\u00c9douard<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_6_18_4' id='input_6_18_4_label' >Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_6_18_5_container' >\n                                    <input type='text' name='input_18.5' id='input_6_18_5' value=''    aria-required='true'    \/>\n                                    <label for='input_6_18_5' id='input_6_18_5_label' >Code postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_18.6' id='input_6_18_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_6_20\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_6_20' >T\u00e9l\u00e9phone R\u00e9s.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_20' id='input_6_20' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_7\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_6_7' >T\u00e9l\u00e9phone Bur.\/Cell.<\/label><div class='ginput_container ginput_container_phone'><input name='input_7' id='input_6_7' type='text' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_22\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_6_22' >Courriel<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_22' id='input_6_22' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_6_19\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >\u00c9tat civil<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_19'><li class='gchoice gchoice_6_19_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.1' type='checkbox'  value='C\u00e9libataire'  id='choice_6_19_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_19_1' id='label_6_19_1'>C\u00e9libataire<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_19_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.2' type='checkbox'  value='En couple'  id='choice_6_19_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_19_2' id='label_6_19_2'>En couple<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_19_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.3' type='checkbox'  value='Marri\u00e9'  id='choice_6_19_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_19_3' id='label_6_19_3'>Marri\u00e9<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_19_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.4' type='checkbox'  value='S\u00e9par\u00e9\/Divorc\u00e9'  id='choice_6_19_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_19_4' id='label_6_19_4'>S\u00e9par\u00e9\/Divorc\u00e9<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_31\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_24\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_6_24' >Relation au patient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_6_24' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_76\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Addresse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_6_76' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_6_76_1_container' >\n                                        <input type='text' name='input_76.1' id='input_6_76_1' value=''    aria-required='true'    \/>\n                                        <label for='input_6_76_1' id='input_6_76_1_label' >No. civique<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_6_76_2_container' >\n                                        <input type='text' name='input_76.2' id='input_6_76_2' value=''     aria-required='false'   \/>\n                                        <label for='input_6_76_2' id='input_6_76_2_label' >Adresse ligne 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_6_76_3_container' >\n                                    <input type='text' name='input_76.3' id='input_6_76_3' value=''    aria-required='true'    \/>\n                                    <label for='input_6_76_3' id='input_6_76_3_label' >Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_6_76_4_container' >\n                                        <select name='input_76.4' id='input_6_76_4'     aria-required='true'    ><option value='' ><\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Terre-Neuve-et-Labrador' >Terre-Neuve-et-Labrador<\/option><option value='Territoires du Nord-Ouest' >Territoires du Nord-Ouest<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='\u00cele du Prince-\u00c9douard' >\u00cele du Prince-\u00c9douard<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_6_76_4' id='input_6_76_4_label' >Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_6_76_5_container' >\n                                    <input type='text' name='input_76.5' id='input_6_76_5' value=''    aria-required='true'    \/>\n                                    <label for='input_6_76_5' id='input_6_76_5_label' >Code postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_76.6' id='input_6_76_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_6_26\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_6_26' >T\u00e9l\u00e9phone R\u00e9s.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_26' id='input_6_26' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_28\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_6_28' >T\u00e9l\u00e9phone Bur.\/Cell.<\/label><div class='ginput_container ginput_container_phone'><input name='input_28' id='input_6_28' type='text' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_29\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_6_29' >Courriel<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_29' id='input_6_29' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_6_30\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >\u00c9tat civil<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_30'><li class='gchoice gchoice_6_30_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.1' type='checkbox'  value='C\u00e9libataire'  id='choice_6_30_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_30_1' id='label_6_30_1'>C\u00e9libataire<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_30_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.2' type='checkbox'  value='En couple'  id='choice_6_30_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_30_2' id='label_6_30_2'>En couple<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_30_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.3' type='checkbox'  value='Marri\u00e9'  id='choice_6_30_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_30_3' id='label_6_30_3'>Marri\u00e9<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_30_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.4' type='checkbox'  value='S\u00e9par\u00e9\/Divorc\u00e9'  id='choice_6_30_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_30_4' id='label_6_30_4'>S\u00e9par\u00e9\/Divorc\u00e9<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_32\" class=\"gfield gsection formtitle field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Histoire M\u00e9dicale<\/h2><div class='gsection_description' id='gfield_description_6_32'>Cocher ce qui s'applique<\/div><\/li><li id=\"field_6_34\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Est-ce que vous \u00eates en bonne sant\u00e9 ?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_34'><li class='gchoice gchoice_6_34_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.1' type='checkbox'  value='Oui'  id='choice_6_34_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_34_1' id='label_6_34_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_34_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.2' type='checkbox'  value='Non'  id='choice_6_34_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_34_2' id='label_6_34_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_35\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_6_35' >Si non, pourquoi ?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_35' id='input_6_35' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_6_36\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Avez-vous \u00e9t\u00e9 hospitalis\u00e9 ?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_36'><li class='gchoice gchoice_6_36_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.1' type='checkbox'  value='Oui'  id='choice_6_36_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_36_1' id='label_6_36_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_36_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.2' type='checkbox'  value='Non'  id='choice_6_36_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_36_2' id='label_6_36_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_37\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_6_37' >Si oui, pourquoi ?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_37' id='input_6_37' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_6_38\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Prenez-vous des m\u00e9dicaments ?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_38'><li class='gchoice gchoice_6_38_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.1' type='checkbox'  value='Oui'  id='choice_6_38_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_38_1' id='label_6_38_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_38_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.2' type='checkbox'  value='Non'  id='choice_6_38_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_38_2' id='label_6_38_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_39\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_6_39' >Si oui, lesquels :<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_39' id='input_6_39' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_6_41\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Faites-vous des r\u00e9actions allergiques ?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_41'><li class='gchoice gchoice_6_41_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.1' type='checkbox'  value='Oui'  id='choice_6_41_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_41_1' id='label_6_41_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_41_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.2' type='checkbox'  value='Non'  id='choice_6_41_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_41_2' id='label_6_41_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_40\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_6_40' >Si oui, lesquelles ?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_40' id='input_6_40' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_6_42\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Fi\u00e8vre rhumatismale, endocardite<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_42'><li class='gchoice gchoice_6_42_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.1' type='checkbox'  value='Oui'  id='choice_6_42_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_42_1' id='label_6_42_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_42_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.2' type='checkbox'  value='Non'  id='choice_6_42_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_42_2' id='label_6_42_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_77\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Probl\u00e8me cardiaque<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_77'><li class='gchoice gchoice_6_77_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.1' type='checkbox'  value='Oui'  id='choice_6_77_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_77_1' id='label_6_77_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_77_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.2' type='checkbox'  value='Non'  id='choice_6_77_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_77_2' id='label_6_77_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_45\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Proth\u00e8se articulaire<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_45'><li class='gchoice gchoice_6_45_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.1' type='checkbox'  value='Oui'  id='choice_6_45_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_45_1' id='label_6_45_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_45_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.2' type='checkbox'  value='Non'  id='choice_6_45_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_45_2' id='label_6_45_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_46\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Probl\u00e8me sanguin, an\u00e9mie<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_46'><li class='gchoice gchoice_6_46_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.1' type='checkbox'  value='Oui'  id='choice_6_46_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_46_1' id='label_6_46_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_46_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.2' type='checkbox'  value='Non'  id='choice_6_46_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_46_2' id='label_6_46_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_47\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Saignement anormal, gu\u00e9rison prolong\u00e9e<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_47'><li class='gchoice gchoice_6_47_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.1' type='checkbox'  value='Oui'  id='choice_6_47_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_47_1' id='label_6_47_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_47_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.2' type='checkbox'  value='Non'  id='choice_6_47_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_47_2' id='label_6_47_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_48\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Asthme, fi\u00e8vre des foins<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_48'><li class='gchoice gchoice_6_48_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.1' type='checkbox'  value='Oui'  id='choice_6_48_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_48_1' id='label_6_48_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_48_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.2' type='checkbox'  value='Non'  id='choice_6_48_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_48_2' id='label_6_48_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_49\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Pression sanguine<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_49'><li class='gchoice gchoice_6_49_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.1' type='checkbox'  value='Oui'  id='choice_6_49_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_49_1' id='label_6_49_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_49_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.2' type='checkbox'  value='Non'  id='choice_6_49_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_49_2' id='label_6_49_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_50\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >\u00c9tourdissements, perte de conscience<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_50'><li class='gchoice gchoice_6_50_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.1' type='checkbox'  value='Oui'  id='choice_6_50_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_50_1' id='label_6_50_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_50_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.2' type='checkbox'  value='Non'  id='choice_6_50_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_50_2' id='label_6_50_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_51\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >H\u00e9patite, maladie du foie<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_51'><li class='gchoice gchoice_6_51_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.1' type='checkbox'  value='Oui'  id='choice_6_51_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_51_1' id='label_6_51_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_51_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.2' type='checkbox'  value='Non'  id='choice_6_51_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_51_2' id='label_6_51_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_52\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Arthrite<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_52'><li class='gchoice gchoice_6_52_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.1' type='checkbox'  value='Oui'  id='choice_6_52_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_52_1' id='label_6_52_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_52_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.2' type='checkbox'  value='Non'  id='choice_6_52_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_52_2' id='label_6_52_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_53\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Troubles r\u00e9naux<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_53'><li class='gchoice gchoice_6_53_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.1' type='checkbox'  value='Oui'  id='choice_6_53_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_53_1' id='label_6_53_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_53_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.2' type='checkbox'  value='Non'  id='choice_6_53_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_53_2' id='label_6_53_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_54\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Maux de t\u00eates fr\u00e9quents, maux d&#039;oreilles<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_54'><li class='gchoice gchoice_6_54_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.1' type='checkbox'  value='Oui'  id='choice_6_54_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_54_1' id='label_6_54_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_54_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.2' type='checkbox'  value='Non'  id='choice_6_54_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_54_2' id='label_6_54_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_55\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Tuberculose, probl\u00e8me pulmonaire<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_55'><li class='gchoice gchoice_6_55_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.1' type='checkbox'  value='Oui'  id='choice_6_55_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_55_1' id='label_6_55_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_55_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.2' type='checkbox'  value='Non'  id='choice_6_55_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_55_2' id='label_6_55_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_56\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Troubles digestifs, ulc\u00e8re d&#039;estomac<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_56'><li class='gchoice gchoice_6_56_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.1' type='checkbox'  value='Oui'  id='choice_6_56_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_56_1' id='label_6_56_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_56_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.2' type='checkbox'  value='Non'  id='choice_6_56_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_56_2' id='label_6_56_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_57\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Probl\u00e8me oculaire, glaucome<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_57'><li class='gchoice gchoice_6_57_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.1' type='checkbox'  value='Oui'  id='choice_6_57_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_57_1' id='label_6_57_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_57_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.2' type='checkbox'  value='Non'  id='choice_6_57_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_57_2' id='label_6_57_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_58\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Epilepsie<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_58'><li class='gchoice gchoice_6_58_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.1' type='checkbox'  value='Oui'  id='choice_6_58_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_58_1' id='label_6_58_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_58_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.2' type='checkbox'  value='Non'  id='choice_6_58_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_58_2' id='label_6_58_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_59\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Sinusite<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_59'><li class='gchoice gchoice_6_59_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.1' type='checkbox'  value='Oui'  id='choice_6_59_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_59_1' id='label_6_59_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_59_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.2' type='checkbox'  value='Non'  id='choice_6_59_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_59_2' id='label_6_59_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_60\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Maladies v\u00e9n\u00e9riennes (MTS), sero-positif (SIDA)<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_60'><li class='gchoice gchoice_6_60_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.1' type='checkbox'  value='Oui'  id='choice_6_60_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_60_1' id='label_6_60_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_60_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.2' type='checkbox'  value='Non'  id='choice_6_60_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_60_2' id='label_6_60_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_61\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Diab\u00e8te<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_61'><li class='gchoice gchoice_6_61_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.1' type='checkbox'  value='Oui'  id='choice_6_61_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_61_1' id='label_6_61_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_61_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.2' type='checkbox'  value='Non'  id='choice_6_61_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_61_2' id='label_6_61_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_62\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Troubles thyro\u00efdiens<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_62'><li class='gchoice gchoice_6_62_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.1' type='checkbox'  value='Oui'  id='choice_6_62_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_62_1' id='label_6_62_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_62_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.2' type='checkbox'  value='Non'  id='choice_6_62_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_62_2' id='label_6_62_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_63\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Traitement aux radiations, chimioth\u00e9rapie<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_63'><li class='gchoice gchoice_6_63_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.1' type='checkbox'  value='Oui'  id='choice_6_63_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_63_1' id='label_6_63_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_63_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.2' type='checkbox'  value='Non'  id='choice_6_63_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_63_2' id='label_6_63_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_64\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Maladies de peau<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_64'><li class='gchoice gchoice_6_64_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.1' type='checkbox'  value='Oui'  id='choice_6_64_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_64_1' id='label_6_64_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_64_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.2' type='checkbox'  value='Non'  id='choice_6_64_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_64_2' id='label_6_64_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_66\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Troubles nerveux<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_66'><li class='gchoice gchoice_6_66_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.1' type='checkbox'  value='Oui'  id='choice_6_66_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_66_1' id='label_6_66_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_66_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.2' type='checkbox'  value='Non'  id='choice_6_66_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_66_2' id='label_6_66_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_65\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Pour femmes - \u00cates-vous enceinte ?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_65'><li class='gchoice gchoice_6_65_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.1' type='checkbox'  value='Oui'  id='choice_6_65_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_65_1' id='label_6_65_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_65_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.2' type='checkbox'  value='Non'  id='choice_6_65_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_65_2' id='label_6_65_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_78\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Ant\u00e9c\u00e9dent de traumatisme \u00e0 la t\u00eate ou au visage<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_78'><li class='gchoice gchoice_6_78_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.1' type='checkbox'  value='Oui'  id='choice_6_78_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_78_1' id='label_6_78_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_78_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.2' type='checkbox'  value='Non'  id='choice_6_78_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_78_2' id='label_6_78_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_68\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Ant\u00e9c\u00e9dent de traumatisme dentaire (fracture, coup sur les dents)<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_68'><li class='gchoice gchoice_6_68_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.1' type='checkbox'  value='Oui'  id='choice_6_68_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_1' id='label_6_68_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_68_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.2' type='checkbox'  value='Non'  id='choice_6_68_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_2' id='label_6_68_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_69\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Extraction(s) dentaire(s)<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_69'><li class='gchoice gchoice_6_69_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.1' type='checkbox'  value='Oui'  id='choice_6_69_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_69_1' id='label_6_69_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_69_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.2' type='checkbox'  value='Non'  id='choice_6_69_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_69_2' id='label_6_69_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_70\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Succion du pouce (pr\u00e9sentement ou pass\u00e9e)<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_70'><li class='gchoice gchoice_6_70_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_70.1' type='checkbox'  value='Oui'  id='choice_6_70_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_70_1' id='label_6_70_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_70_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_70.2' type='checkbox'  value='Non'  id='choice_6_70_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_70_2' id='label_6_70_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_71\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Est-ce que les amygdales et\/ou les ad\u00e9no\u00efdes sont enlev\u00e9es<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_71'><li class='gchoice gchoice_6_71_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.1' type='checkbox'  value='Oui'  id='choice_6_71_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_71_1' id='label_6_71_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_71_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.2' type='checkbox'  value='Non'  id='choice_6_71_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_71_2' id='label_6_71_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_72\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Probl\u00e8me de language<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_72'><li class='gchoice gchoice_6_72_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.1' type='checkbox'  value='Oui'  id='choice_6_72_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_72_1' id='label_6_72_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_72_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.2' type='checkbox'  value='Non'  id='choice_6_72_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_72_2' id='label_6_72_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_73\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Respiration buccale<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_73'><li class='gchoice gchoice_6_73_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.1' type='checkbox'  value='Oui'  id='choice_6_73_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_73_1' id='label_6_73_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_73_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.2' type='checkbox'  value='Non'  id='choice_6_73_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_73_2' id='label_6_73_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_75\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Grincement des dents<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_75'><li class='gchoice gchoice_6_75_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_75.1' type='checkbox'  value='Oui'  id='choice_6_75_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_75_1' id='label_6_75_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_75_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_75.2' type='checkbox'  value='Non'  id='choice_6_75_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_75_2' id='label_6_75_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_74\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Traitement\/consultation orthodontique pass\u00e9(es)<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_74'><li class='gchoice gchoice_6_74_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.1' type='checkbox'  value='Oui'  id='choice_6_74_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_74_1' id='label_6_74_1'>Oui<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_74_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.2' type='checkbox'  value='Non'  id='choice_6_74_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_74_2' id='label_6_74_2'>Non<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_79\" class=\"gfield 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