{"id":37216,"date":"2024-04-17T10:46:34","date_gmt":"2024-04-17T08:46:34","guid":{"rendered":"https:\/\/palamosdivecenter.com\/questionari-medic\/"},"modified":"2024-04-17T10:46:35","modified_gmt":"2024-04-17T08:46:35","slug":"questionari-medic","status":"publish","type":"page","link":"https:\/\/palamosdivecenter.com\/ca\/questionari-medic\/","title":{"rendered":"Q\u00fcestionari M\u00e8dic"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"37216\" class=\"elementor elementor-37216 elementor-33400\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section data-particle_enable=\"false\" data-particle-mobile-disabled=\"false\" class=\"elementor-section elementor-top-section elementor-element elementor-element-72f7921 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"72f7921\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-e69d032\" data-id=\"e69d032\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-3dcf425 elementor-widget elementor-widget-eael-adv-tabs\" data-id=\"3dcf425\" data-element_type=\"widget\" data-widget_type=\"eael-adv-tabs.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t        <div data-scroll-on-click=\"no\" data-scroll-speed=\"300\" id=\"eael-advance-tabs-3dcf425\" class=\"eael-advance-tabs eael-tabs-horizontal eael-tab-auto-active \" data-tabid=\"3dcf425\">\n            <div class=\"eael-tabs-nav\">\n                <ul class=\"eael-tab-inline-icon\" role=\"tablist\">\n                                            <li id=\"\" class=\"inactive eael-tab-item-trigger eael-tab-nav-item\" aria-selected=\"true\" data-tab=\"1\" role=\"tab\" tabindex=\"0\" aria-controls=\"-tab\" aria-expanded=\"false\">\n                            \n                                                                <img decoding=\"async\" src=\"https:\/\/palamosdivecenter.com\/wp-content\/uploads\/2022\/05\/1.png\" alt=\"Espa\u00f1ol\">\n                                                            \n                                                            <span class=\"eael-tab-title title-after-icon\" ><\/span>                            \n                                                    <\/li>\n                                            <li id=\"\" class=\"inactive eael-tab-item-trigger eael-tab-nav-item\" aria-selected=\"false\" data-tab=\"2\" role=\"tab\" tabindex=\"-1\" aria-controls=\"-tab\" aria-expanded=\"false\">\n                            \n                                                                <img decoding=\"async\" src=\"https:\/\/palamosdivecenter.com\/wp-content\/uploads\/2022\/05\/2.png\" alt=\"Catal\u00e1n\">\n                                                            \n                                                            <span class=\"eael-tab-title title-after-icon\" ><\/span>                            \n                                                    <\/li>\n                                            <li id=\"\" class=\"inactive eael-tab-item-trigger eael-tab-nav-item\" aria-selected=\"false\" data-tab=\"3\" role=\"tab\" tabindex=\"-1\" aria-controls=\"-tab\" aria-expanded=\"false\">\n                            \n                                                                <img decoding=\"async\" src=\"https:\/\/palamosdivecenter.com\/wp-content\/uploads\/2022\/05\/3.png\" alt=\"Ingl\u00e9s\">\n                                                            \n                                                            <span class=\"eael-tab-title title-after-icon\" ><\/span>                            \n                                                    <\/li>\n                                            <li id=\"\" class=\"inactive eael-tab-item-trigger eael-tab-nav-item\" aria-selected=\"false\" data-tab=\"4\" role=\"tab\" tabindex=\"-1\" aria-controls=\"-tab\" aria-expanded=\"false\">\n                            \n                                                                <img decoding=\"async\" src=\"https:\/\/palamosdivecenter.com\/wp-content\/uploads\/2022\/05\/4.png\" alt=\"Franc\u00e8s\">\n                                                            \n                                                            <span class=\"eael-tab-title title-after-icon\" ><\/span>                            \n                                                    <\/li>\n                                    <\/ul>\n            <\/div>\n            \n            <div class=\"eael-tabs-content\">\n\t\t        \n                    <div id=\"-tab\" class=\"clearfix eael-tab-content-item inactive\" data-title-link=\"-tab\">\n\t\t\t\t        <div class='fluentform ff-default fluentform_wrapper_2 ffs_default_wrap'><form data-form_id=\"2\" id=\"fluentform_2\" class=\"frm-fluent-form fluent_form_2 ff-el-form-top ff_form_instance_2_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_2_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Cuestionario M\u00e9dico<\/legend>        <div\n                style=\"display: none!important; position: absolute!important; transform: translateX(1000%)!important;\"\n                class=\"ff-el-group ff-hpsf-container\"\n        >\n            <div class=\"ff-el-input--label asterisk-right\">\n                <label for=\"ff_2_item_sf\" aria-label=\"Contact\">\n                    Contact                <\/label>\n            <\/div>\n            <div class=\"ff-el-input--content\">\n                <input type=\"text\"\n                       name=\"item_2__fluent_sf\"\n                       class=\"ff-el-form-control\"\n                       id=\"ff_2_item_sf\"\n                \/>\n            <\/div>\n        <\/div>\n        <input type='hidden' name='__fluent_form_embded_post_id' value='37216' \/><input type=\"hidden\" id=\"_fluentform_2_fluentformnonce\" name=\"_fluentform_2_fluentformnonce\" value=\"27024ddcb1\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/ca\/wp-json\/wp\/v2\/pages\/37216\" \/><div data-type=\"name-element\" data-name=\"names_3\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group  ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_2_names_3_first_name_' >Nombre<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_3[first_name]\" id=\"ff_2_names_3_first_name_\" class=\"ff-el-form-control\" placeholder=\"Nombre\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group  ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_2_names_3_last_name_' >Apellido<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_3[last_name]\" id=\"ff_2_names_3_last_name_\" class=\"ff-el-form-control\" placeholder=\"Apellido\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_2_input_text_10' aria-label=\"DNI\">DNI<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_10\" class=\"ff-el-form-control\" placeholder=\"DNI\" data-name=\"input_text_10\" id=\"ff_2_input_text_10\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_2_datetime_2' aria-label=\"Fecha de nacimiento\">Fecha de nacimiento<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Fecha de nacimiento Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime_2\" id=\"ff_2_datetime_2\" class=\"ff-el-form-control ff-el-datepicker\" placeholder=\"Fecha de nacimiento\" data-name=\"datetime_2\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_2_email_2' aria-label=\"Correo electr\u00f3nico\">Correo electr\u00f3nico<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email_2\" id=\"ff_2_email_2\" class=\"ff-el-form-control\" placeholder=\"Correo electr\u00f3nico\" data-name=\"email_2\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_2_numeric-field_3' aria-label=\"N\u00famero de Tel\u00e9fono\">N\u00famero de Tel\u00e9fono<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_3\" id=\"ff_2_numeric-field_3\" class=\"ff-el-form-control\" placeholder=\"Tel\u00e9fono\" data-name=\"numeric-field_3\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_2_dropdown_1' aria-label=\"Nivel de buceo\">Nivel de buceo<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_1\" id=\"ff_2_dropdown_1\" class=\"ff-el-form-control\" data-name=\"dropdown_1\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\">Seleccionar<\/option><option value=\"Nunca he buceado\"  >Nunca he buceado<\/option><option value=\"Principiante\"  >Principiante<\/option><option value=\"Intermedio\"  >Intermedio<\/option><option value=\"Avanzado\"  >Avanzado<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_2_country-list' aria-label=\"Pa\u00eds\">Pa\u00eds<\/label><\/div><div class='ff-el-input--content'><select name=\"country-list\" id=\"ff_2_country-list\" class=\"ff-el-form-control\" placeholder=\"Seleccionar pa\u00eds\" data-name=\"country-list\" aria-invalid='false' aria-required=true><option value=''>Seleccionar pa\u00eds<\/option><option value='AF' >Afghanistan<\/option><option value='AX' >Aland Islands<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctica<\/option><option value='AG' >Antigua and Barbuda<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BY' >Belarus<\/option><option value='PW' >Belau<\/option><option value='BE' >Belgium<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Saint Eustatius and Saba<\/option><option value='BA' >Bosnia and Herzegovina<\/option><option value='BW' >Botswana<\/option><option value='BV' >Bouvet Island<\/option><option value='BR' >Brazil<\/option><option value='IO' >British Indian Ocean Territory<\/option><option value='VG' >British Virgin Islands<\/option><option value='BN' >Brunei<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='KH' >Cambodia<\/option><option value='CM' >Cameroon<\/option><option value='CA' >Canada<\/option><option value='CV' >Cape Verde<\/option><option value='KY' >Cayman Islands<\/option><option value='CF' >Central African Republic<\/option><option value='TD' >Chad<\/option><option value='CL' >Chile<\/option><option value='CN' >China<\/option><option value='CX' >Christmas Island<\/option><option value='CC' >Cocos (Keeling) Islands<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comoros<\/option><option value='CK' >Cook Islands<\/option><option value='CR' >Costa Rica<\/option><option value='HR' >Croatia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura&ccedil;ao<\/option><option value='CY' >Cyprus<\/option><option value='CZ' >Czech Republic<\/option><option value='CD' >Democratic Republic of the Congo (Kinshasa)<\/option><option value='DK' >Denmark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominica<\/option><option value='DO' >Dominican Republic<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egypt<\/option><option value='SV' >El Salvador<\/option><option value='GQ' >Equatorial Guinea<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='ET' >Ethiopia<\/option><option value='FK' >Falkland Islands<\/option><option value='FO' >Faroe Islands<\/option><option value='FJ' >Fiji<\/option><option value='FI' >Finland<\/option><option value='FR' >France<\/option><option value='GF' >French Guiana<\/option><option value='PF' >French Polynesia<\/option><option value='TF' >French Southern Territories<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germany<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GR' >Greece<\/option><option value='GL' >Greenland<\/option><option value='GD' >Grenada<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GN' >Guinea<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HM' >Heard Island and McDonald Islands<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hungary<\/option><option value='IS' >Iceland<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Ireland<\/option><option value='IM' >Isle of Man<\/option><option value='IL' >Israel<\/option><option value='IT' >Italy<\/option><option value='CI' >Ivory Coast<\/option><option value='JM' >Jamaica<\/option><option value='JP' >Japan<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordan<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='XK' >Kosovo<\/option><option value='KW' >Kuwait<\/option><option value='KG' >Kyrgyzstan<\/option><option value='LA' >Laos<\/option><option value='LV' >Latvia<\/option><option value='LB' >Lebanon<\/option><option value='LS' >Lesotho<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libya<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lithuania<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao S.A.R., China<\/option><option value='MK' >Macedonia<\/option><option value='MG' >Madagascar<\/option><option value='MW' >Malawi<\/option><option value='MY' >Malaysia<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MH' >Marshall Islands<\/option><option value='MQ' >Martinique<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldova<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MA' >Morocco<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NL' >Netherlands<\/option><option value='NC' >New Caledonia<\/option><option value='NZ' >New Zealand<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NF' >Norfolk Island<\/option><option value='KP' >North Korea<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norway<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PS' >Palestinian Territory<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua New Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Poland<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='QA' >Qatar<\/option><option value='CG' >Republic of the Congo (Brazzaville)<\/option><option value='RE' >Reunion<\/option><option value='RO' >Romania<\/option><option value='RU' >Russia<\/option><option value='RW' >Rwanda<\/option><option value='BL' >Saint Barth&eacute;lemy<\/option><option value='SH' >Saint Helena<\/option><option value='KN' >Saint Kitts and Nevis<\/option><option value='LC' >Saint Lucia<\/option><option value='SX' >Saint Martin (Dutch part)<\/option><option value='MF' >Saint Martin (French part)<\/option><option value='PM' >Saint Pierre and Miquelon<\/option><option value='VC' >Saint Vincent and the Grenadines<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tome and Principe<\/option><option value='SA' >Saudi Arabia<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SK' >Slovakia<\/option><option value='SI' >Slovenia<\/option><option value='SB' >Solomon Islands<\/option><option value='SO' >Somalia<\/option><option value='ZA' >South Africa<\/option><option value='GS' >South Georgia\/Sandwich Islands<\/option><option value='KR' >South Korea<\/option><option value='SS' >South Sudan<\/option><option value='ES' >Spain<\/option><option value='LK' >Sri Lanka<\/option><option value='SD' >Sudan<\/option><option value='SR' >Suriname<\/option><option value='SJ' >Svalbard and Jan Mayen<\/option><option value='SZ' >Swaziland<\/option><option value='SE' >Sweden<\/option><option value='CH' >Switzerland<\/option><option value='SY' >Syria<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzania<\/option><option value='TH' >Thailand<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad and Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >Turkey<\/option><option value='TM' >Turkmenistan<\/option><option value='TC' >Turks and Caicos Islands<\/option><option value='TV' >Tuvalu<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='AE' >United Arab Emirates<\/option><option value='GB' >United Kingdom (UK)<\/option><option value='US' >United States (US)<\/option><option value='UM' >United States (US) Minor Outlying Islands<\/option><option value='VI' >United States (US) Virgin Islands<\/option><option value='UY' >Uruguay<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VA' >Vatican<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='WF' >Wallis and Futuna<\/option><option value='EH' >Western Sahara<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><\/select><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-2_1\" ><p style=\"text-align: justify\" align=\"justify\"><strong>ANEXO I<\/strong><\/p>\n<p style=\"text-align: justify\" align=\"justify\"><strong>Cuestionario sobre el estado de salud para la pr\u00e1ctica del buceo recreativo<\/strong><\/p>\n<p style=\"text-align: left\" align=\"center\">El buceo requiere una buena salud f\u00edsica y mental. Hay algunes condiciones m\u00e9dicas que pueden ser peligrosas durante la pr\u00e1ctica del buceo, y que se enumeran a continuaci\u00f3n. Aquellos que tienen o est\u00e1n predispuestos a cualquiera de estas condiciones, deben ser evaluados por un m\u00e9dico. Este Cuestionario de M\u00e9dico del Buceador proporciona una base para determinar si Ud. Debe buscar esa evaluaci\u00f3n. Si tiene alguna inquietud acerca de su estado f\u00edsico para la pr\u00e1ctica del buceo y no est\u00e1n representades en este formulario, consulte con su m\u00e9dico antes de bucear. Las referancias a \u201cbuceo\u201d en este formulario abarcan tanto el buceo recreativo con equipo aut\u00f3nomo como el buceo en apnea. Este formulario est\u00e1 dise\u00f1ado principalmente como un examen m\u00e9dico inicial para los nuevos buceadores, pero tambi\u00e9n es apropiado para los buceadores que reciben educaci\u00f3n continua. Por su Seguridad y la de otras persones que pueden bucear con usted, responda a todas las preguntes honestamente.<\/p>\n<p style=\"text-align: justify\" align=\"center\"><strong>INSTRUCCIONES<\/strong><\/p>\n<p style=\"text-align: justify\" align=\"center\">Complete este cuestionario como requisito previo para el entranimiento de apnea o de buceo con equipo autonomo.<br \/>Nota para las mujeres: Si usted esta embarazada, o intenta quedar embarazada, <strong>,no bucee.<\/strong><\/p><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Certificado M\u00e9dico\">Certificado M\u00e9dico<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_19ef31565c3335a9d509c486d2947d89><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si, tengo certificado\"  id='checkbox_19ef31565c3335a9d509c486d2947d89' aria-label='Si, tengo certificado' aria-invalid='false' aria-required=true> <span>Si, tengo certificado<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_6c3db1faa88ec9f1fa16ba3c84c0d96b><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No, no tengo certificado\"  id='checkbox_6c3db1faa88ec9f1fa16ba3c84c0d96b' aria-label='No, no tengo certificado' aria-invalid='false' aria-required=true> <span>No, no tengo certificado<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"1. He tenido problemas con mis pulmones o respiraci\u00f3n, coraz\u00f3n o sangre.\">1. He tenido problemas con mis pulmones o respiraci\u00f3n, coraz\u00f3n o sangre.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_40_10f2ae8b355d12b72acc4d6c8b5c0ebd><input  type=\"checkbox\" name=\"checkbox_40[]\" data-name=\"checkbox_40\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_40_10f2ae8b355d12b72acc4d6c8b5c0ebd' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_40_3ad169d0caada2a582f4a6d7de782455><input  type=\"checkbox\" name=\"checkbox_40[]\" data-name=\"checkbox_40\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_40_3ad169d0caada2a582f4a6d7de782455' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo o he tenido: Cirug\u00eda tor\u00e1cica, cirug\u00eda card\u00edaca, cirug\u00eda de v\u00e1lvula card\u00edaca, colocaci\u00f3n de \u201cstent\u201do neumot\u00f3rax (pulm\u00f3ncolapsado).\">Tengo o he tenido: Cirug\u00eda tor\u00e1cica, cirug\u00eda card\u00edaca, cirug\u00eda de v\u00e1lvula card\u00edaca, colocaci\u00f3n de \u201cstent\u201do neumot\u00f3rax (pulm\u00f3ncolapsado).<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_3_40ba18317558de3e35c8674fd3015802><input  type=\"checkbox\" name=\"checkbox_3[]\" data-name=\"checkbox_3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_3_40ba18317558de3e35c8674fd3015802' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_3_a1eccc8549c49586ec57b18f284e61fd><input  type=\"checkbox\" name=\"checkbox_3[]\" data-name=\"checkbox_3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_3_a1eccc8549c49586ec57b18f284e61fd' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo o he tenido: Asma, sibilancies, alergias graves, fiebre del heno o v\u00edas respiratorias congestionades en los \u00faltimos 12 meses que limite mi actividad f\u00edsica o ejercicio.\">Tengo o he tenido: Asma, sibilancies, alergias graves, fiebre del heno o v\u00edas respiratorias congestionades en los \u00faltimos 12 meses que limite mi actividad f\u00edsica o ejercicio.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_4_37f4a35a20ce4ab1c1a68f453c886949><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_4_37f4a35a20ce4ab1c1a68f453c886949' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_4_b017611b54942e7d3b8569d2cd39d783><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_4_b017611b54942e7d3b8569d2cd39d783' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo o he tenido: Un problema o enfermedad que involucra mi coraz\u00f3n como: anginade pecho, dolor en el pecho en el esfuerzo, insufici\u00e8ncia card\u00edaca, edema pulmonar, miocardiopatia o accidente cerebrovascular, o estoy tomando medicament\u00f3s para cualquier afecci\u00f3n card\u00edaca.\">Tengo o he tenido: Un problema o enfermedad que involucra mi coraz\u00f3n como: anginade pecho, dolor en el pecho en el esfuerzo, insufici\u00e8ncia card\u00edaca, edema pulmonar, miocardiopatia o accidente cerebrovascular, o estoy tomando medicament\u00f3s para cualquier afecci\u00f3n card\u00edaca.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_5_a03092a3bb55d5c17a59bbf329dbc8e8><input  type=\"checkbox\" name=\"checkbox_5[]\" data-name=\"checkbox_5\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_5_a03092a3bb55d5c17a59bbf329dbc8e8' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_5_45ba50eb3507bd536c1e9068db470c91><input  type=\"checkbox\" name=\"checkbox_5[]\" data-name=\"checkbox_5\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_5_45ba50eb3507bd536c1e9068db470c91' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo o he tenido: Bronquitis recurrente y tos persistente en los \u00faltimos 12 meses, o han sido diagnosticados con emfisema.\">Tengo o he tenido: Bronquitis recurrente y tos persistente en los \u00faltimos 12 meses, o han sido diagnosticados con emfisema.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_6_f8b0630ce813634b57e748cabe431332><input  type=\"checkbox\" name=\"checkbox_6[]\" data-name=\"checkbox_6\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_6_f8b0630ce813634b57e748cabe431332' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_6_3d48f5067b4e773b676198485a01d221><input  type=\"checkbox\" name=\"checkbox_6[]\" data-name=\"checkbox_6\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_6_3d48f5067b4e773b676198485a01d221' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"2. Tengo m\u00e1s de 45 a\u00f1os\">2. Tengo m\u00e1s de 45 a\u00f1os<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_1_9535f5e7fa8d68f3acd8e6f302e16f28><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_1_9535f5e7fa8d68f3acd8e6f302e16f28' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_1_adb9732185243a8e3acd0d94b7fef7e5><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_1_adb9732185243a8e3acd0d94b7fef7e5' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo + de 45 a\u00f1os y:  Actualmente fumo o inhalo nicotina por otros medios\">Tengo + de 45 a\u00f1os y:  Actualmente fumo o inhalo nicotina por otros medios<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_7_4d5c24fcb5520e8ad08e722cb313a496><input  type=\"checkbox\" name=\"checkbox_7[]\" data-name=\"checkbox_7\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_7_4d5c24fcb5520e8ad08e722cb313a496' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_7_9867e644e5fd152332cc18a36c1c4955><input  type=\"checkbox\" name=\"checkbox_7[]\" data-name=\"checkbox_7\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_7_9867e644e5fd152332cc18a36c1c4955' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo + de 45 a\u00f1os y: Tengo nivel alto de colesterol.\">Tengo + de 45 a\u00f1os y: Tengo nivel alto de colesterol.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_8_5e2a07cafcfdc76d78a5bac03ea5bbcd><input  type=\"checkbox\" name=\"checkbox_8[]\" data-name=\"checkbox_8\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_8_5e2a07cafcfdc76d78a5bac03ea5bbcd' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_8_4fb179438cab940c725ad50e3dd3a637><input  type=\"checkbox\" name=\"checkbox_8[]\" data-name=\"checkbox_8\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_8_4fb179438cab940c725ad50e3dd3a637' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo + de 45 a\u00f1os y: Tengo presi\u00f3n arterial alta\">Tengo + de 45 a\u00f1os y: Tengo presi\u00f3n arterial alta<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_10_437e03e48349f8ec98dddf0547fd5f2e><input  type=\"checkbox\" name=\"checkbox_10[]\" data-name=\"checkbox_10\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_10_437e03e48349f8ec98dddf0547fd5f2e' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_10_9d8001e90facf1c98701dfb9e50dcc7f><input  type=\"checkbox\" name=\"checkbox_10[]\" data-name=\"checkbox_10\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_10_9d8001e90facf1c98701dfb9e50dcc7f' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo + de 45 a\u00f1os y: He tenido un familiar (de 1er. o 2\u00b0 grado de consanguinidad) que muri\u00f3 de muerte s\u00fabita o de enfermedad card\u00edaca o accidente cerebrovascular antes de los 50 a\u00f1os, o tengo antecedentes familiares de enfermedad card\u00edaca antes de los 50 a\u00f1os (incluidos ritmos card\u00edacos anormales, enfermedad de las arterias coronaries o cardiomiopatia)\">Tengo + de 45 a\u00f1os y: He tenido un familiar (de 1er. o 2\u00b0 grado de consanguinidad) que muri\u00f3 de muerte s\u00fabita o de enfermedad card\u00edaca o accidente cerebrovascular antes de los 50 a\u00f1os, o tengo antecedentes familiares de enfermedad card\u00edaca antes de los 50 a\u00f1os (incluidos ritmos card\u00edacos anormales, enfermedad de las arterias coronaries o cardiomiopatia)<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_9_4cc64689485ce9493a549b319e4d0876><input  type=\"checkbox\" name=\"checkbox_9[]\" data-name=\"checkbox_9\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_9_4cc64689485ce9493a549b319e4d0876' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_9_6be75f6591c3680d10062d2d82f30fe2><input  type=\"checkbox\" name=\"checkbox_9[]\" data-name=\"checkbox_9\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_9_6be75f6591c3680d10062d2d82f30fe2' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"3. Me cuesta realizar ejercicio moderado (por ejemplo, caminar 1,6 kil\u00f3metros en 12 minutos o nadar 200 metros sin descansar), o no he podido participar en una actividad f\u00edsica normal debido a razones de estado f\u00edsico o de salud en los \u00faltimos 12 meses.\">3. Me cuesta realizar ejercicio moderado (por ejemplo, caminar 1,6 kil\u00f3metros en 12 minutos o nadar 200 metros sin descansar), o no he podido participar en una actividad f\u00edsica normal debido a razones de estado f\u00edsico o de salud en los \u00faltimos 12 meses.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_2_595f6645465124e37ec7cd76bc413d2a><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_2_595f6645465124e37ec7cd76bc413d2a' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_2_77615173a72fe033683b364bcec255ee><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_2_77615173a72fe033683b364bcec255ee' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"4. He tenido problemas con mis ojos, o\u00eddos, o fosas nasales o senos paranasales.\">4. He tenido problemas con mis ojos, o\u00eddos, o fosas nasales o senos paranasales.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_12_dc5f82bdd8835c0f3fd526d4827bd40f><input  type=\"checkbox\" name=\"checkbox_12[]\" data-name=\"checkbox_12\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_12_dc5f82bdd8835c0f3fd526d4827bd40f' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_12_12ded566de7006f1b97a5c1258d0c707><input  type=\"checkbox\" name=\"checkbox_12[]\" data-name=\"checkbox_12\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_12_12ded566de7006f1b97a5c1258d0c707' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo o he tenido: Cirug\u00eda sinusal en los ultimos 6 meses.\">Tengo o he tenido: Cirug\u00eda sinusal en los ultimos 6 meses.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_13_9db7ab413d5bab67e33af00178320f73><input  type=\"checkbox\" name=\"checkbox_13[]\" data-name=\"checkbox_13\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_13_9db7ab413d5bab67e33af00178320f73' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_13_a5013ebe322a070971527dbb2625d3ec><input  type=\"checkbox\" name=\"checkbox_13[]\" data-name=\"checkbox_13\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_13_a5013ebe322a070971527dbb2625d3ec' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo o he tenido: Enfermedades del o\u00eddo o cirug\u00eda del o\u00eddo, p\u00e9rdida de audici\u00f3n o alteracions del equilibrio.\">Tengo o he tenido: Enfermedades del o\u00eddo o cirug\u00eda del o\u00eddo, p\u00e9rdida de audici\u00f3n o alteracions del equilibrio.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_11_0ead334af14fffcfef6975aca32355ee><input  type=\"checkbox\" name=\"checkbox_11[]\" data-name=\"checkbox_11\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_11_0ead334af14fffcfef6975aca32355ee' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_11_b6ea8bfcc7056beffa4265f37cb91403><input  type=\"checkbox\" name=\"checkbox_11[]\" data-name=\"checkbox_11\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_11_b6ea8bfcc7056beffa4265f37cb91403' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo o he tenido: Sinusitis recurrente en los \u00faltimos 12 meses.\">Tengo o he tenido: Sinusitis recurrente en los \u00faltimos 12 meses.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_14_df5c2b01d1852afa8cc2d3b031beb57e><input  type=\"checkbox\" name=\"checkbox_14[]\" data-name=\"checkbox_14\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_14_df5c2b01d1852afa8cc2d3b031beb57e' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_14_1f5eb81dfc9270c54f3976ea67170c2f><input  type=\"checkbox\" name=\"checkbox_14[]\" data-name=\"checkbox_14\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_14_1f5eb81dfc9270c54f3976ea67170c2f' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo o he tenido: Cirug\u00eda ocultar en los \u00faltimos 3 meses.\">Tengo o he tenido: Cirug\u00eda ocultar en los \u00faltimos 3 meses.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_18_72d01f934f8b0efd241cb7c0f0d9e950><input  type=\"checkbox\" name=\"checkbox_18[]\" data-name=\"checkbox_18\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_18_72d01f934f8b0efd241cb7c0f0d9e950' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_18_b5619c31d5f8c197307ed34ae7415a65><input  type=\"checkbox\" name=\"checkbox_18[]\" data-name=\"checkbox_18\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_18_b5619c31d5f8c197307ed34ae7415a65' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"5. He tenido una cirug\u00eda en los \u00faltimos 12 meses, o tengo problemas continuos relacionados con una cirug\u00eda anterior.\">5. He tenido una cirug\u00eda en los \u00faltimos 12 meses, o tengo problemas continuos relacionados con una cirug\u00eda anterior.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_16_b6e71fe6bfd77868d098701ff44b9c2b><input  type=\"checkbox\" name=\"checkbox_16[]\" data-name=\"checkbox_16\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_16_b6e71fe6bfd77868d098701ff44b9c2b' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_16_6f2f3f0873aafc122c048e2a3ddb1a82><input  type=\"checkbox\" name=\"checkbox_16[]\" data-name=\"checkbox_16\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_16_6f2f3f0873aafc122c048e2a3ddb1a82' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"6. He perdido el conocimiento, he tenido dolores de cabeza por migrana, convulsiones, accidente cerebrovascular, lesi\u00f3n significativa en la cabeza, o he sufrido de lesi\u00f3n o enfermedad neurol\u00f2gica persistente.\">6. He perdido el conocimiento, he tenido dolores de cabeza por migrana, convulsiones, accidente cerebrovascular, lesi\u00f3n significativa en la cabeza, o he sufrido de lesi\u00f3n o enfermedad neurol\u00f2gica persistente.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_17_54647277226e41f0c5b2994623f27052><input  type=\"checkbox\" name=\"checkbox_17[]\" data-name=\"checkbox_17\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_17_54647277226e41f0c5b2994623f27052' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_17_51bc35523f5a16c77c8d2301ed931d95><input  type=\"checkbox\" name=\"checkbox_17[]\" data-name=\"checkbox_17\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_17_51bc35523f5a16c77c8d2301ed931d95' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo o he tenido: Lesi\u00f3n en la cabeza con p\u00e9rdida de conciencia en los \u00faltimos 5 a\u00f1os.\">Tengo o he tenido: Lesi\u00f3n en la cabeza con p\u00e9rdida de conciencia en los \u00faltimos 5 a\u00f1os.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_15_c294926d37776c40442503cfdb6ea505><input  type=\"checkbox\" name=\"checkbox_15[]\" data-name=\"checkbox_15\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_15_c294926d37776c40442503cfdb6ea505' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_15_87682e0f4f2f83775f37948f9e2565e6><input  type=\"checkbox\" name=\"checkbox_15[]\" data-name=\"checkbox_15\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_15_87682e0f4f2f83775f37948f9e2565e6' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo o he tenido: Lesiones o enfermedades neurol\u00f3gicas persistentes.\">Tengo o he tenido: Lesiones o enfermedades neurol\u00f3gicas persistentes.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_19_2a1ade5ed31f98dd7bf4e6acb1000716><input  type=\"checkbox\" name=\"checkbox_19[]\" data-name=\"checkbox_19\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_19_2a1ade5ed31f98dd7bf4e6acb1000716' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_19_91ec3d96eed8efc1965856aae4462ce2><input  type=\"checkbox\" name=\"checkbox_19[]\" data-name=\"checkbox_19\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_19_91ec3d96eed8efc1965856aae4462ce2' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo o he tenido: Dolores de cabeza recurrentes por migra\u00f1a en los \u00faltimos 12 meses, o tomo medicament\u00f3s para prevenirlos.\">Tengo o he tenido: Dolores de cabeza recurrentes por migra\u00f1a en los \u00faltimos 12 meses, o tomo medicament\u00f3s para prevenirlos.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_20_cf816a59f8951d3f58e709893d308480><input  type=\"checkbox\" name=\"checkbox_20[]\" data-name=\"checkbox_20\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_20_cf816a59f8951d3f58e709893d308480' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_20_ae2aaa6377dfe235c6249e6b8b7cdc72><input  type=\"checkbox\" name=\"checkbox_20[]\" data-name=\"checkbox_20\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_20_ae2aaa6377dfe235c6249e6b8b7cdc72' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo o he tenido: Epilepsia, ataques o convulsiones, o tomo medicament\u00f3s para prevenirlos.\">Tengo o he tenido: Epilepsia, ataques o convulsiones, o tomo medicament\u00f3s para prevenirlos.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_21_36c43a676cad725204440662272bde8d><input  type=\"checkbox\" name=\"checkbox_21[]\" data-name=\"checkbox_21\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_21_36c43a676cad725204440662272bde8d' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_21_b09d38b5ebff122ef92857a9ac5ba840><input  type=\"checkbox\" name=\"checkbox_21[]\" data-name=\"checkbox_21\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_21_b09d38b5ebff122ef92857a9ac5ba840' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"7. He tenido problemas psicol\u00f3gicos, me diagnosticaran una discapacidad de aprendizaje, trastorno de la personalidad, ataques de p\u00e0nico o una adicc\u00ed\u00f3n a las drogas o el alcohol.\">7. He tenido problemas psicol\u00f3gicos, me diagnosticaran una discapacidad de aprendizaje, trastorno de la personalidad, ataques de p\u00e0nico o una adicc\u00ed\u00f3n a las drogas o el alcohol.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_27_d6e3828a2ed3d2cb25f49932f5279af9><input  type=\"checkbox\" name=\"checkbox_27[]\" data-name=\"checkbox_27\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_27_d6e3828a2ed3d2cb25f49932f5279af9' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_27_bc8464a9f5e7e6fa579ec7ee10979316><input  type=\"checkbox\" name=\"checkbox_27[]\" data-name=\"checkbox_27\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_27_bc8464a9f5e7e6fa579ec7ee10979316' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo o he tenido: Salud conductual, problemas mentales o psicol\u00f3gicos que requieran tratamiento m\u00e9dico o psiqui\u00e1trico.\">Tengo o he tenido: Salud conductual, problemas mentales o psicol\u00f3gicos que requieran tratamiento m\u00e9dico o psiqui\u00e1trico.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_23_d8a435380a4397f206bc1249aa4a1208><input  type=\"checkbox\" name=\"checkbox_23[]\" data-name=\"checkbox_23\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_23_d8a435380a4397f206bc1249aa4a1208' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_23_86695469bfc72a589e0c08abb9be3eb7><input  type=\"checkbox\" name=\"checkbox_23[]\" data-name=\"checkbox_23\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_23_86695469bfc72a589e0c08abb9be3eb7' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo o he tenido: Depresi\u00f3n Mayor, tendencia suicida, ataques de p\u00e1nico, trastorno bipolar descontrolado que requiere medicaci\u00f3n\/tratamientopsiqui\u00e1trico.\">Tengo o he tenido: Depresi\u00f3n Mayor, tendencia suicida, ataques de p\u00e1nico, trastorno bipolar descontrolado que requiere medicaci\u00f3n\/tratamientopsiqui\u00e1trico.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_24_8494aaaeb5738207a13ab6adf94c08e2><input  type=\"checkbox\" name=\"checkbox_24[]\" data-name=\"checkbox_24\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_24_8494aaaeb5738207a13ab6adf94c08e2' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_24_a7c0e532bd26a764b810bf1f84de38e0><input  type=\"checkbox\" name=\"checkbox_24[]\" data-name=\"checkbox_24\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_24_a7c0e532bd26a764b810bf1f84de38e0' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo o he tenido: He sido diagnosticado con una condici\u00f3n de salud mental o un trastorno de aprendizaje o desarrollo que requiere atenci\u00f3n continua.\">Tengo o he tenido: He sido diagnosticado con una condici\u00f3n de salud mental o un trastorno de aprendizaje o desarrollo que requiere atenci\u00f3n continua.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_25_59beb8da1700923ed9a133340bbaadfd><input  type=\"checkbox\" name=\"checkbox_25[]\" data-name=\"checkbox_25\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_25_59beb8da1700923ed9a133340bbaadfd' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_25_dc0c5ce5237f4ce92ea541d8caadd737><input  type=\"checkbox\" name=\"checkbox_25[]\" data-name=\"checkbox_25\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_25_dc0c5ce5237f4ce92ea541d8caadd737' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo o he tenido: Una adicci\u00f3n a las drogas o al alcohol que requiere tratamiento en los \u00faltimos 5 a\u00f1os.\">Tengo o he tenido: Una adicci\u00f3n a las drogas o al alcohol que requiere tratamiento en los \u00faltimos 5 a\u00f1os.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_28_73ce87a95c64e756edb18af6e59dca94><input  type=\"checkbox\" name=\"checkbox_28[]\" data-name=\"checkbox_28\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_28_73ce87a95c64e756edb18af6e59dca94' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_28_c453561b4e17a8f6290f88a6b8b8dcd1><input  type=\"checkbox\" name=\"checkbox_28[]\" data-name=\"checkbox_28\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_28_c453561b4e17a8f6290f88a6b8b8dcd1' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"8. He tenido problemas de espalda, h\u00e8rnia, \u00falceras o diabetes.\">8. He tenido problemas de espalda, h\u00e8rnia, \u00falceras o diabetes.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_22_8bceb12caeac3d2666766994491fdcb7><input  type=\"checkbox\" name=\"checkbox_22[]\" data-name=\"checkbox_22\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_22_8bceb12caeac3d2666766994491fdcb7' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_22_0375c7ebf7390520430b3b4fa898f0af><input  type=\"checkbox\" name=\"checkbox_22[]\" data-name=\"checkbox_22\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_22_0375c7ebf7390520430b3b4fa898f0af' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo o he tenido: Problemas recurrentes en la espalda en los \u00faltimos 6 meses que limitan mi actividad diaria.\">Tengo o he tenido: Problemas recurrentes en la espalda en los \u00faltimos 6 meses que limitan mi actividad diaria.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_26_074283d885ec54b5d3e4e664a53e9577><input  type=\"checkbox\" name=\"checkbox_26[]\" data-name=\"checkbox_26\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_26_074283d885ec54b5d3e4e664a53e9577' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_26_d229ac496207852a8af0eed8cbea7e27><input  type=\"checkbox\" name=\"checkbox_26[]\" data-name=\"checkbox_26\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_26_d229ac496207852a8af0eed8cbea7e27' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo o he tenido: Cirug\u00eda de espalda o culmna vertebral en los \u00faltimos 12 meses.\">Tengo o he tenido: Cirug\u00eda de espalda o culmna vertebral en los \u00faltimos 12 meses.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_29_4a2d74609349677f00b6002ce3be6458><input  type=\"checkbox\" name=\"checkbox_29[]\" data-name=\"checkbox_29\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_29_4a2d74609349677f00b6002ce3be6458' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_29_5776b7b806807b26e04a7ab6664e2314><input  type=\"checkbox\" name=\"checkbox_29[]\" data-name=\"checkbox_29\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_29_5776b7b806807b26e04a7ab6664e2314' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo o he tenido: Diabetes, ya sea controlada por insulina o por dieta, o diabetis gestacional en los \u00faltimos 12 meses.\">Tengo o he tenido: Diabetes, ya sea controlada por insulina o por dieta, o diabetis gestacional en los \u00faltimos 12 meses.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_30_cc33d2092b0dbbfdb916239b515ec29f><input  type=\"checkbox\" name=\"checkbox_30[]\" data-name=\"checkbox_30\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_30_cc33d2092b0dbbfdb916239b515ec29f' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_30_73825d1d73fc9d090fc865daef934f1c><input  type=\"checkbox\" name=\"checkbox_30[]\" data-name=\"checkbox_30\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_30_73825d1d73fc9d090fc865daef934f1c' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo o he tenido: Una hernia no corregida que limita mis habilitades f\u00edsicas.\">Tengo o he tenido: Una hernia no corregida que limita mis habilitades f\u00edsicas.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_31_c9fde77ea4308db779b36c6988e61356><input  type=\"checkbox\" name=\"checkbox_31[]\" data-name=\"checkbox_31\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_31_c9fde77ea4308db779b36c6988e61356' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_31_0dcfdea915f46ec514ec4f851c0b5e8a><input  type=\"checkbox\" name=\"checkbox_31[]\" data-name=\"checkbox_31\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_31_0dcfdea915f46ec514ec4f851c0b5e8a' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo o he tenido: \u00dalceras activas o no tratadas, heridas problem\u00e1ticas o cirug\u00eda de \u00falceres en los \u00faltimos 6 meses.\">Tengo o he tenido: \u00dalceras activas o no tratadas, heridas problem\u00e1ticas o cirug\u00eda de \u00falceres en los \u00faltimos 6 meses.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_32_c9ff5cf6bf724df12d7d73521f3df755><input  type=\"checkbox\" name=\"checkbox_32[]\" data-name=\"checkbox_32\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_32_c9ff5cf6bf724df12d7d73521f3df755' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_32_f22b20a361ab066ccb83f9d54c61a21a><input  type=\"checkbox\" name=\"checkbox_32[]\" data-name=\"checkbox_32\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_32_f22b20a361ab066ccb83f9d54c61a21a' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"9. He tenido problemas estomacales o intestinales, incluyendo diarrea reciente.\">9. He tenido problemas estomacales o intestinales, incluyendo diarrea reciente.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_33_b7d6a4bebef82757c1bf5abcb832cb49><input  type=\"checkbox\" name=\"checkbox_33[]\" data-name=\"checkbox_33\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_33_b7d6a4bebef82757c1bf5abcb832cb49' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_33_013c094b7738029546f161aaf4f9972a><input  type=\"checkbox\" name=\"checkbox_33[]\" data-name=\"checkbox_33\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_33_013c094b7738029546f161aaf4f9972a' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo: Cirug\u00eda de ostom\u00eda y no tengo autorizaci\u00f3n m\u00e9dica para nadar o participar en actividad f\u00edsica.\">Tengo: Cirug\u00eda de ostom\u00eda y no tengo autorizaci\u00f3n m\u00e9dica para nadar o participar en actividad f\u00edsica.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_34_b6395ff21a006b0e3fa22a28f29967f8><input  type=\"checkbox\" name=\"checkbox_34[]\" data-name=\"checkbox_34\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_34_b6395ff21a006b0e3fa22a28f29967f8' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_34_4b982a335a49af5e74b9e86b04f8fc8e><input  type=\"checkbox\" name=\"checkbox_34[]\" data-name=\"checkbox_34\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_34_4b982a335a49af5e74b9e86b04f8fc8e' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo: Deshidrataci\u00f3n que requiere intervenci\u00f3n m\u00e9dica para nadar o participar en actividad f\u00edsica.\">Tengo: Deshidrataci\u00f3n que requiere intervenci\u00f3n m\u00e9dica para nadar o participar en actividad f\u00edsica.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_35_f2ba6cbcb08d89c7a00a4a8125a9bb61><input  type=\"checkbox\" name=\"checkbox_35[]\" data-name=\"checkbox_35\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_35_f2ba6cbcb08d89c7a00a4a8125a9bb61' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_35_d6c8578a1ddde82360f194750bc92550><input  type=\"checkbox\" name=\"checkbox_35[]\" data-name=\"checkbox_35\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_35_d6c8578a1ddde82360f194750bc92550' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo: \u00dalceras estomacales o intestinales activas o no tratadas o cirug\u00eda de \u00falceres en los \u00faltimos 6 meses.\">Tengo: \u00dalceras estomacales o intestinales activas o no tratadas o cirug\u00eda de \u00falceres en los \u00faltimos 6 meses.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_36_5911f104ac0b55002a0b6569543f2649><input  type=\"checkbox\" name=\"checkbox_36[]\" data-name=\"checkbox_36\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_36_5911f104ac0b55002a0b6569543f2649' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_36_fef55f2e74852efb9ff19159e224dce1><input  type=\"checkbox\" name=\"checkbox_36[]\" data-name=\"checkbox_36\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_36_fef55f2e74852efb9ff19159e224dce1' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo: Ardor de est\u00f3mago frecuente, regurgitaci\u00f3n o enfermedad por reflujo gastroesof\u00e1gico (ERGE).\">Tengo: Ardor de est\u00f3mago frecuente, regurgitaci\u00f3n o enfermedad por reflujo gastroesof\u00e1gico (ERGE).<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_37_2ad873a8bd4fadc12939a56719311364><input  type=\"checkbox\" name=\"checkbox_37[]\" data-name=\"checkbox_37\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_37_2ad873a8bd4fadc12939a56719311364' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_37_afd94ecc75ff1678885311f9ee5a3041><input  type=\"checkbox\" name=\"checkbox_37[]\" data-name=\"checkbox_37\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_37_afd94ecc75ff1678885311f9ee5a3041' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo: Colitis ulcerosa activa o no controlada o enfermedad de Crohn.\">Tengo: Colitis ulcerosa activa o no controlada o enfermedad de Crohn.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_38_649898c58a5e4330c03aabcc5fe4e826><input  type=\"checkbox\" name=\"checkbox_38[]\" data-name=\"checkbox_38\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_38_649898c58a5e4330c03aabcc5fe4e826' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_38_ad7da7d15ecd4833e7dcc64076dc9b68><input  type=\"checkbox\" name=\"checkbox_38[]\" data-name=\"checkbox_38\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_38_ad7da7d15ecd4833e7dcc64076dc9b68' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tengo: Cirug\u00eda bari\u00e0trica en los \u00faltimos 12 meses.\">Tengo: Cirug\u00eda bari\u00e0trica en los \u00faltimos 12 meses.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_39_f0d5c66dd7794e574d77f656a2a64f81><input  type=\"checkbox\" name=\"checkbox_39[]\" data-name=\"checkbox_39\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_39_f0d5c66dd7794e574d77f656a2a64f81' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_39_8350e9f25f5f2e7aa916ecff36a687e9><input  type=\"checkbox\" name=\"checkbox_39[]\" data-name=\"checkbox_39\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_39_8350e9f25f5f2e7aa916ecff36a687e9' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-2_2\" ><p><strong>Firma del Participante<\/strong><\/p>\n<p style=\"text-align: justify\">Si respondi\u00f3 NO a las 1O preguntas anteriores, no se requiere una evaluaci\u00f3n m\u00e9dica. Por favor, lea y acepte la declaraci\u00f3n del participante a continuaci\u00f3n con la fecha y su firma.<br \/>Declaraci\u00f3n del Participante: He respondido a todas las preguntas honestamente, y entiendo que acepto la responsabilidad por cualquier consecuencia resultante de cualquier pregunta que pueda haber respondido inexactamente o por no haber revelado cualquier condici\u00f3n de salud existente o pasada.<br \/>Firma del participante (o, si es menor de edad, se requiere la firma del padre\/tutor del participante.)<\/p><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_1  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Firma\">Firma<\/label><\/div><div class='ff-el-input--content'><input type='text' name='signature' class='force-hide'>\n\n<div class=\"fluentform-signature-pad-wrapper\">\n    <canvas id='signature_2' \n            class='fluentform-signature-pad' \n            data-form-id='2'\n            data-pen-color='#333'\n            data-pen-size='2'\n            style='\n                background-color: #ffffff;\n                border: 2px dashed #FF2D00;\n                width: fit-content;\n            '\n            height=\"200\"\n    ><\/canvas>\n\n    <div class=\"ff-el-signature__actions\">\n        <div class='fluentform-signature-pad-actions'>\n            <button type='button' class='fluentform-signature-button fluentform-signature-clear'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 561 561\" xml:space=\"preserve\"><g><g id=\"loop\"><path d=\"M280.5,76.5V0l-102,102l102,102v-76.5c84.15,0,153,68.85,153,153c0,25.5-7.65,51-17.85,71.4l38.25,38.25C471.75,357,484.5,321.3,484.5,280.5C484.5,168.3,392.7,76.5,280.5,76.5z M280.5,433.5c-84.15,0-153-68.85-153-153c0-25.5,7.65-51,17.85-71.4l-38.25-38.25C89.25,204,76.5,239.7,76.5,280.5c0,112.2,91.8,204,204,204V561l102-102l-102-102V433.5z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n            \n            <button type='button' class='fluentform-signature-button fluentform-signature-undo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 497.25 497.25\" xml:space=\"preserve\"><g><g id=\"undo\"><path d=\"M248.625,89.25V0l-127.5,127.5l127.5,127.5V140.25c84.15,0,153,68.85,153,153c0,84.15-68.85,153-153,153c-84.15,0-153-68.85-153-153h-51c0,112.2,91.8,204,204,204s204-91.8,204-204S360.825,89.25,248.625,89.25z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n\n            <button type='button' class='fluentform-signature-button fluentform-signature-redo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 485.212 485.212\" xml:space=\"preserve\"><g><path d=\"M242.607,424.559c-75.252,0-136.468-61.209-136.468-136.465c0-75.252,61.216-136.466,136.468-136.466v90.978l151.629-121.302L242.607,0v90.978c-108.687,0-197.117,88.432-197.117,197.117c0,108.691,88.43,197.118,197.117,197.118c108.687,0,197.114-88.427,197.114-197.118h-60.645C379.077,363.35,317.859,424.559,242.607,424.559z\"\/><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n        <\/div>\n\n        <div class='ff-el-signature__actions-hint fluentform-signature-hint'>Firma aqu\u00ed<\/div>\n    <\/div>\n<\/div>\n<\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_5\"  class='ff-t-container ff-column-container ff_columns_total_3  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 34%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_2_datetime' aria-label=\"Fecha\">Fecha<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Fecha Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime\" id=\"ff_2_datetime\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 34%;'><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 34%;'><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-2_3\" ><p style=\"text-align: justify\"><strong>Si respondi\u00f3 S\u00cd<\/strong> a las preguntas 3, 5 o 10 anteriores o a cualquiera de las preguntas de la p\u00e1gina 2, lea y acepte la declaraci\u00f3n anterior con la fecha y su firma, y lleve el Formulario de <strong>Evaluaci\u00f3n del M\u00e9dico a su m\u00e9dico<\/strong>, para una evaluaci\u00f3n m\u00e9dica. La participaci\u00f3n en un programa de entrenamiento de buceo, requiere la evaluaci\u00f3n y aprobaci\u00f3n de su m\u00e9dico.<\/p><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='Terms and Conditions: He le\u00eddo y Acepto el  Aviso Legal y la Pol\u00edtica de Privacidad Contains 2 links. Use tab navigation to review.' class='ff-el-form-check-label ff_tc_label' for=gdpr-agreement_517f85e4ede74f0f13cd14218f42936a><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"gdpr-agreement\" class=\"ff-el-form-check-input ff_gdpr_field\" data-name=\"gdpr-agreement\" id=\"gdpr-agreement_517f85e4ede74f0f13cd14218f42936a\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'>He le\u00eddo y Acepto el <a href=\"https:\/\/palamosdivecenter.com\/aviso-legal\"> Aviso Legal<\/a> y la <a href=\"https:\/\/palamosdivecenter.com\/politica-privacidad\">Pol\u00edtica de Privacidad<\/a><\/div><\/label><\/div><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='Doy mi consentimiento para que este sitio web almacene mi informaci\u00f3n enviada para que puedan responder a mi consulta' class='ff-el-form-check-label ff_tc_label' for=gdpr-agreement_1_62a8fe7c2004a6140f686b9ad03a369c><span 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ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_2_names_3_first_name_' >Nom<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_3[first_name]\" id=\"ff_3_2_names_3_first_name_\" class=\"ff-el-form-control\" placeholder=\"Nom\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group  ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_2_names_3_last_name_' >Cognoms<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_3[last_name]\" id=\"ff_3_2_names_3_last_name_\" class=\"ff-el-form-control\" placeholder=\"Cognoms\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_2_input_text_10' aria-label=\"DNI\">DNI<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_10\" class=\"ff-el-form-control\" placeholder=\"DNI\" data-name=\"input_text_10\" id=\"ff_3_2_input_text_10\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_2_datetime_2' aria-label=\"Fecha de nacimiento\">Fecha de nacimiento<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Fecha de nacimiento Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime_2\" id=\"ff_3_2_datetime_2\" class=\"ff-el-form-control ff-el-datepicker\" placeholder=\"Fecha de nacimiento\" data-name=\"datetime_2\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_2_email_2' aria-label=\"Correu electr\u00f2nic\">Correu electr\u00f2nic<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email_2\" id=\"ff_3_2_email_2\" class=\"ff-el-form-control\" placeholder=\"Correu electr\u00f2nic\" data-name=\"email_2\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_2_numeric-field_3' aria-label=\"N\u00famero de tel\u00e8fon\">N\u00famero de tel\u00e8fon<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_3\" id=\"ff_3_2_numeric-field_3\" class=\"ff-el-form-control\" placeholder=\"Tel\u00e8fon\" data-name=\"numeric-field_3\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_2_dropdown_1' aria-label=\"Nivell de busseig\">Nivell de busseig<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_1\" id=\"ff_3_2_dropdown_1\" class=\"ff-el-form-control\" data-name=\"dropdown_1\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\">Seleccionar<\/option><option value=\"Mai he bussejat\"  >Mai he bussejat<\/option><option value=\"Principiant\"  >Principiant<\/option><option value=\"Intermig\"  >Intermig<\/option><option value=\"Avan\u00e7at\"  >Avan\u00e7at<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_2_country-list' aria-label=\"Pa\u00eds\">Pa\u00eds<\/label><\/div><div class='ff-el-input--content'><select name=\"country-list\" id=\"ff_3_2_country-list\" class=\"ff-el-form-control\" placeholder=\"Seleccionar pa\u00eds\" data-name=\"country-list\" aria-invalid='false' aria-required=true><option value=''>Seleccionar pa\u00eds<\/option><option value='AF' >Afghanistan<\/option><option value='AX' >Aland Islands<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctica<\/option><option value='AG' >Antigua and Barbuda<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BY' >Belarus<\/option><option value='PW' >Belau<\/option><option value='BE' >Belgium<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Saint Eustatius and Saba<\/option><option value='BA' >Bosnia and Herzegovina<\/option><option value='BW' >Botswana<\/option><option value='BV' >Bouvet Island<\/option><option value='BR' >Brazil<\/option><option value='IO' >British Indian Ocean Territory<\/option><option value='VG' >British Virgin Islands<\/option><option value='BN' >Brunei<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='KH' >Cambodia<\/option><option value='CM' >Cameroon<\/option><option value='CA' >Canada<\/option><option value='CV' >Cape Verde<\/option><option value='KY' >Cayman Islands<\/option><option value='CF' >Central African Republic<\/option><option value='TD' >Chad<\/option><option value='CL' >Chile<\/option><option value='CN' >China<\/option><option value='CX' >Christmas Island<\/option><option value='CC' >Cocos (Keeling) Islands<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comoros<\/option><option value='CK' >Cook Islands<\/option><option value='CR' >Costa Rica<\/option><option value='HR' >Croatia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura&ccedil;ao<\/option><option value='CY' >Cyprus<\/option><option value='CZ' >Czech Republic<\/option><option value='CD' >Democratic Republic of the Congo (Kinshasa)<\/option><option value='DK' >Denmark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominica<\/option><option value='DO' >Dominican Republic<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egypt<\/option><option value='SV' >El Salvador<\/option><option value='GQ' >Equatorial Guinea<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='ET' >Ethiopia<\/option><option value='FK' >Falkland Islands<\/option><option value='FO' >Faroe Islands<\/option><option value='FJ' >Fiji<\/option><option value='FI' >Finland<\/option><option value='FR' >France<\/option><option value='GF' >French Guiana<\/option><option value='PF' >French Polynesia<\/option><option value='TF' >French Southern Territories<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germany<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GR' >Greece<\/option><option value='GL' >Greenland<\/option><option value='GD' >Grenada<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GN' >Guinea<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HM' >Heard Island and McDonald Islands<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hungary<\/option><option value='IS' >Iceland<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Ireland<\/option><option value='IM' >Isle of Man<\/option><option value='IL' >Israel<\/option><option value='IT' >Italy<\/option><option value='CI' >Ivory Coast<\/option><option value='JM' >Jamaica<\/option><option value='JP' >Japan<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordan<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='XK' >Kosovo<\/option><option value='KW' >Kuwait<\/option><option value='KG' >Kyrgyzstan<\/option><option value='LA' >Laos<\/option><option value='LV' >Latvia<\/option><option value='LB' >Lebanon<\/option><option value='LS' >Lesotho<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libya<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lithuania<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao S.A.R., China<\/option><option value='MK' >Macedonia<\/option><option value='MG' >Madagascar<\/option><option value='MW' >Malawi<\/option><option value='MY' >Malaysia<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MH' >Marshall Islands<\/option><option value='MQ' >Martinique<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldova<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MA' >Morocco<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NL' >Netherlands<\/option><option value='NC' >New Caledonia<\/option><option value='NZ' >New Zealand<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NF' >Norfolk Island<\/option><option value='KP' >North Korea<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norway<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PS' >Palestinian Territory<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua New Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Poland<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='QA' >Qatar<\/option><option value='CG' >Republic of the Congo (Brazzaville)<\/option><option value='RE' >Reunion<\/option><option value='RO' >Romania<\/option><option value='RU' >Russia<\/option><option value='RW' >Rwanda<\/option><option value='BL' >Saint Barth&eacute;lemy<\/option><option value='SH' >Saint Helena<\/option><option value='KN' >Saint Kitts and Nevis<\/option><option value='LC' >Saint Lucia<\/option><option value='SX' >Saint Martin (Dutch part)<\/option><option value='MF' >Saint Martin (French part)<\/option><option value='PM' >Saint Pierre and Miquelon<\/option><option value='VC' >Saint Vincent and the Grenadines<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tome and Principe<\/option><option value='SA' >Saudi Arabia<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SK' >Slovakia<\/option><option value='SI' >Slovenia<\/option><option value='SB' >Solomon Islands<\/option><option value='SO' >Somalia<\/option><option value='ZA' >South Africa<\/option><option value='GS' >South Georgia\/Sandwich Islands<\/option><option value='KR' >South Korea<\/option><option value='SS' >South Sudan<\/option><option value='ES' >Spain<\/option><option value='LK' >Sri Lanka<\/option><option value='SD' >Sudan<\/option><option value='SR' >Suriname<\/option><option value='SJ' >Svalbard and Jan Mayen<\/option><option value='SZ' >Swaziland<\/option><option value='SE' >Sweden<\/option><option value='CH' >Switzerland<\/option><option value='SY' >Syria<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzania<\/option><option value='TH' >Thailand<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad and Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >Turkey<\/option><option value='TM' >Turkmenistan<\/option><option value='TC' >Turks and Caicos Islands<\/option><option value='TV' >Tuvalu<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='AE' >United Arab Emirates<\/option><option value='GB' >United Kingdom (UK)<\/option><option value='US' >United States (US)<\/option><option value='UM' >United States (US) Minor Outlying Islands<\/option><option value='VI' >United States (US) Virgin Islands<\/option><option value='UY' >Uruguay<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VA' >Vatican<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='WF' >Wallis and Futuna<\/option><option value='EH' >Western Sahara<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><\/select><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_1\" ><p style=\"text-align: left\"><strong>ANNEX I<\/strong><\/p>\n<p style=\"text-align: left\">Q\u00fcestionari sobre l&#8217;estat de salut per a la pr\u00e0ctica del busseig recreatiu<\/p>\n<p style=\"text-align: left\">El busseig requereix una bona salut f\u00edsica i mental. Hi ha algunes condicions m\u00e8diques que poden ser perilloses durant la pr\u00e0ctica del busseig, i que s&#8217;enumeren a continuaci\u00f3. Aquells que tenen o estan predisposats a qualsevol daquestes condicions, han de ser avaluats per un metge. Aquest Q\u00fcestionari de Metge del Bussejador proporciona una base per determinar si heu de cercar aquesta avaluaci\u00f3. Si teniu alguna inquietud sobre el vostre estat f\u00edsic per a la pr\u00e0ctica del busseig i no estan representades en aquest formulari, consulteu amb el vostre metge abans de bussejar. Les refer\u00e0ncies a \u201cbusseig\u201d en aquest formulari abasten tant el busseig recreatiu amb equip aut\u00f2nom com el busseig en apnea. Aquest formulari est\u00e0 dissenyat principalment com un examen m\u00e8dic inicial per als nous bussejadors, per\u00f2 tamb\u00e9 \u00e9s apropiat per als bussejadors que reben educaci\u00f3 continua. Per la vostra seguretat i la d&#8217;altres persones que poden bussejar amb vosaltres, responeu a totes les preguntes honestament.<\/p>\n<p style=\"text-align: left\"><strong>INSTRUCCIONS<\/strong><\/p>\n<p style=\"text-align: left\">Completeu aquest q\u00fcestionari com a requisit previ per a l&#8217;entrenament d&#8217;apnea o de busseig amb equip aut\u00f2nom.<br \/>Nota per a les dones: Si vost\u00e8 est\u00e0 embarassada, o intenta quedar embarassada, no bussegi.<\/p><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Certificat M\u00e8dic\">Certificat M\u00e8dic<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_ab7be8f69a6dc753c022c68c3bc6d081><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si, tinc certificat\"  id='checkbox_ab7be8f69a6dc753c022c68c3bc6d081' aria-label='Si, tinc certificat' aria-invalid='false' aria-required=true> <span>Si, tinc certificat<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_106e6f9066de06ba3ebf3a7e7f010420><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No, no tinc certificat\"  id='checkbox_106e6f9066de06ba3ebf3a7e7f010420' aria-label='No, no tinc certificat' aria-invalid='false' aria-required=true> <span>No, no tinc certificat<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"1. He tingut problemes amb els meus pulmons o respiraci\u00f3, cor o sang.\">1. He tingut problemes amb els meus pulmons o respiraci\u00f3, cor o sang.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_40_33ee7093525648467882931d6c5320bd><input  type=\"checkbox\" name=\"checkbox_40[]\" data-name=\"checkbox_40\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_40_33ee7093525648467882931d6c5320bd' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_40_460b2fab0e93524026688f2da3e024b8><input  type=\"checkbox\" name=\"checkbox_40[]\" data-name=\"checkbox_40\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_40_460b2fab0e93524026688f2da3e024b8' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc o he tingut: Cirurgia tor\u00e0cica, cirurgia card\u00edaca, cirurgia de v\u00e0lvula card\u00edaca, col\u00b7locaci\u00f3 de stent o pneumot\u00f2rax (pulm\u00f3 col\u00b7lapsat).\">Tinc o he tingut: Cirurgia tor\u00e0cica, cirurgia card\u00edaca, cirurgia de v\u00e0lvula card\u00edaca, col\u00b7locaci\u00f3 de stent o pneumot\u00f2rax (pulm\u00f3 col\u00b7lapsat).<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_3_fe490c17744aabb2133888ee4d0c3cfe><input  type=\"checkbox\" name=\"checkbox_3[]\" data-name=\"checkbox_3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_3_fe490c17744aabb2133888ee4d0c3cfe' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_3_789b3f56ef6882bb908706bafbfc2f63><input  type=\"checkbox\" name=\"checkbox_3[]\" data-name=\"checkbox_3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_3_789b3f56ef6882bb908706bafbfc2f63' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc o he tingut: Asma, sibil\u00e0ncies, al\u00b7l\u00e8rgies greus, febre del fenc o vies respirat\u00f2ries congestionades en els darrers 12 mesos que limiti la meva activitat f\u00edsica o exercici.\">Tinc o he tingut: Asma, sibil\u00e0ncies, al\u00b7l\u00e8rgies greus, febre del fenc o vies respirat\u00f2ries congestionades en els darrers 12 mesos que limiti la meva activitat f\u00edsica o exercici.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_4_541f8b79bec04c4971d7ef756f75e3ce><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_4_541f8b79bec04c4971d7ef756f75e3ce' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_4_9215789fdc16f643046bfeae71601256><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_4_9215789fdc16f643046bfeae71601256' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc o he tingut: Un problema o malaltia que involucra el meu cor com: anginade pit, dolor al pit a l&#039;esfor\u00e7, insufici\u00e8ncia card\u00edaca, edema pulmonar, miocardiopatia o accident cerebrovascular, o estic prenent medicament\u00f3s per a qualsevol afecci\u00f3 card\u00edaca.\">Tinc o he tingut: Un problema o malaltia que involucra el meu cor com: anginade pit, dolor al pit a l&#8217;esfor\u00e7, insufici\u00e8ncia card\u00edaca, edema pulmonar, miocardiopatia o accident cerebrovascular, o estic prenent medicament\u00f3s per a qualsevol afecci\u00f3 card\u00edaca.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_5_55bf2d89768817f8a0c8031865ff51e9><input  type=\"checkbox\" name=\"checkbox_5[]\" data-name=\"checkbox_5\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_5_55bf2d89768817f8a0c8031865ff51e9' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_5_88a348f7273542cd5db3b622f103c484><input  type=\"checkbox\" name=\"checkbox_5[]\" data-name=\"checkbox_5\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_5_88a348f7273542cd5db3b622f103c484' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc o he tingut: Bronquitis recurrent i tos persistent en els darrers 12 mesos, o han estat diagnosticats amb emfisema.\">Tinc o he tingut: Bronquitis recurrent i tos persistent en els darrers 12 mesos, o han estat diagnosticats amb emfisema.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_6_ebe8a0b35c741d7bfbc042892abd96a3><input  type=\"checkbox\" name=\"checkbox_6[]\" data-name=\"checkbox_6\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_6_ebe8a0b35c741d7bfbc042892abd96a3' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_6_3236ff28eff99ebe56d2e8d6b6d59fe5><input  type=\"checkbox\" name=\"checkbox_6[]\" data-name=\"checkbox_6\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_6_3236ff28eff99ebe56d2e8d6b6d59fe5' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"2. Tinc m\u00e9s de 45 anys\">2. Tinc m\u00e9s de 45 anys<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_1_d8665342c453d29ad5441cca61412478><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_1_d8665342c453d29ad5441cca61412478' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_1_addb2e77302fe2e6721c3c1fcf1199ce><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_1_addb2e77302fe2e6721c3c1fcf1199ce' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc + de 45 anys i: Actualment fumo o inhalo nicotina per altres mitjans\">Tinc + de 45 anys i: Actualment fumo o inhalo nicotina per altres mitjans<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_7_df35c0884da2c09175342f3a1f2fd37f><input  type=\"checkbox\" name=\"checkbox_7[]\" data-name=\"checkbox_7\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_7_df35c0884da2c09175342f3a1f2fd37f' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_7_18acab71bb4ee212218209e689e02812><input  type=\"checkbox\" name=\"checkbox_7[]\" data-name=\"checkbox_7\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_7_18acab71bb4ee212218209e689e02812' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc + de 45 anys i: Tinc nivell alt de colesterol.\">Tinc + de 45 anys i: Tinc nivell alt de colesterol.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_8_361d0b4268d9e1429f0693dd973e1ec8><input  type=\"checkbox\" name=\"checkbox_8[]\" data-name=\"checkbox_8\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_8_361d0b4268d9e1429f0693dd973e1ec8' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_8_426788fb4e32f863520c3396e814d7b1><input  type=\"checkbox\" name=\"checkbox_8[]\" data-name=\"checkbox_8\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_8_426788fb4e32f863520c3396e814d7b1' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc + de 45 anys i: Tinc pressi\u00f3 arterial alta\">Tinc + de 45 anys i: Tinc pressi\u00f3 arterial alta<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_10_e7d6efa6dc61a753231bbb8f6c11fc9b><input  type=\"checkbox\" name=\"checkbox_10[]\" data-name=\"checkbox_10\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_10_e7d6efa6dc61a753231bbb8f6c11fc9b' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_10_75179bdc613c62316286934e778b8d8b><input  type=\"checkbox\" name=\"checkbox_10[]\" data-name=\"checkbox_10\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_10_75179bdc613c62316286934e778b8d8b' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc + de 45 anys i: He tingut un familiar (de 1r. o 2n grau de consanguinitat) que va morir de mort sobtada o de malaltia card\u00edaca o accident cerebrovascular abans dels 50 anys, o tinc antecedents familiars de malaltia card\u00edaca abans dels 50 anys (inclosos ritmes card\u00edacs anormals, malaltia de les art\u00e8ries coron\u00e0ries o cardiomiopatia)\">Tinc + de 45 anys i: He tingut un familiar (de 1r. o 2n grau de consanguinitat) que va morir de mort sobtada o de malaltia card\u00edaca o accident cerebrovascular abans dels 50 anys, o tinc antecedents familiars de malaltia card\u00edaca abans dels 50 anys (inclosos ritmes card\u00edacs anormals, malaltia de les art\u00e8ries coron\u00e0ries o cardiomiopatia)<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_9_2d44e6c8dc415716ea7bda94683070f0><input  type=\"checkbox\" name=\"checkbox_9[]\" data-name=\"checkbox_9\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_9_2d44e6c8dc415716ea7bda94683070f0' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_9_fb76936eede9a12a0532d036a852def5><input  type=\"checkbox\" name=\"checkbox_9[]\" data-name=\"checkbox_9\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_9_fb76936eede9a12a0532d036a852def5' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"3. Em costa fer exercici moderat (per exemple, caminar 1,6 quil\u00f2metres en 12 minuts o nedar 200 metres sense descansar), o no he pogut participar en una activitat f\u00edsica normal a causa de raons d&#039;estat f\u00edsic o de salut en els darrers 12 minuts. mesos.\">3. Em costa fer exercici moderat (per exemple, caminar 1,6 quil\u00f2metres en 12 minuts o nedar 200 metres sense descansar), o no he pogut participar en una activitat f\u00edsica normal a causa de raons d&#8217;estat f\u00edsic o de salut en els darrers 12 minuts. mesos.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_2_0bfc4df9bfe2625e9afe5792001122e2><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_2_0bfc4df9bfe2625e9afe5792001122e2' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_2_c3f982dd5dbb6d2ebf7fba3d7e5de110><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_2_c3f982dd5dbb6d2ebf7fba3d7e5de110' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"4. He tingut problemes amb els meus ulls, orelles, i fosses nasals o pits paranasals.\">4. He tingut problemes amb els meus ulls, orelles, i fosses nasals o pits paranasals.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_12_d33a8db15e8f9bc37e57972d99085ffe><input  type=\"checkbox\" name=\"checkbox_12[]\" data-name=\"checkbox_12\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_12_d33a8db15e8f9bc37e57972d99085ffe' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_12_7a8a335e091998e59ce3eb5e51ef21b7><input  type=\"checkbox\" name=\"checkbox_12[]\" data-name=\"checkbox_12\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_12_7a8a335e091998e59ce3eb5e51ef21b7' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc o he tingut: Cirurgia sinusal en els darrers 6 mesos.\">Tinc o he tingut: Cirurgia sinusal en els darrers 6 mesos.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_13_35f5e072de17f6044f82e9571027378e><input  type=\"checkbox\" name=\"checkbox_13[]\" data-name=\"checkbox_13\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_13_35f5e072de17f6044f82e9571027378e' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_13_8d4d3e858b0037f1d8ee7a7fe8cf39e1><input  type=\"checkbox\" name=\"checkbox_13[]\" data-name=\"checkbox_13\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_13_8d4d3e858b0037f1d8ee7a7fe8cf39e1' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc o he tingut: Malalties de l&#039;orella o cirurgia de l&#039;orella, p\u00e8rdua d&#039;audici\u00f3 o alteracions de l&#039;equilibri.\">Tinc o he tingut: Malalties de l&#8217;orella o cirurgia de l&#8217;orella, p\u00e8rdua d&#8217;audici\u00f3 o alteracions de l&#8217;equilibri.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_11_df5422d94f121a42eeee4d8f2e5b07ea><input  type=\"checkbox\" name=\"checkbox_11[]\" data-name=\"checkbox_11\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_11_df5422d94f121a42eeee4d8f2e5b07ea' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_11_e6b4dbfe57642b98f00a485d8b921dc4><input  type=\"checkbox\" name=\"checkbox_11[]\" data-name=\"checkbox_11\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_11_e6b4dbfe57642b98f00a485d8b921dc4' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc o he tingut: Sinusitis recurrent en els darrers 12 mesos.\">Tinc o he tingut: Sinusitis recurrent en els darrers 12 mesos.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_14_f781f9fade4051c2d9efd89d3a6219fb><input  type=\"checkbox\" name=\"checkbox_14[]\" data-name=\"checkbox_14\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_14_f781f9fade4051c2d9efd89d3a6219fb' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_14_236b5244c5b3101da31a24db086d9397><input  type=\"checkbox\" name=\"checkbox_14[]\" data-name=\"checkbox_14\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_14_236b5244c5b3101da31a24db086d9397' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc o he tingut: Cirurgia amagar en els darrers 3 mesos.\">Tinc o he tingut: Cirurgia amagar en els darrers 3 mesos.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_18_b65d994d6ccb87b180e337d59a9d1b62><input  type=\"checkbox\" name=\"checkbox_18[]\" data-name=\"checkbox_18\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_18_b65d994d6ccb87b180e337d59a9d1b62' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_18_e20e905f7d1fb87c55c08fad3a9b44e8><input  type=\"checkbox\" name=\"checkbox_18[]\" data-name=\"checkbox_18\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_18_e20e905f7d1fb87c55c08fad3a9b44e8' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"5. He tingut una cirurgia en els darrers 12 mesos, o tinc problemes continus relacionats amb una cirurgia anterior.\">5. He tingut una cirurgia en els darrers 12 mesos, o tinc problemes continus relacionats amb una cirurgia anterior.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_16_d7d4e4627270454eceaf83d7a37fd7e2><input  type=\"checkbox\" name=\"checkbox_16[]\" data-name=\"checkbox_16\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_16_d7d4e4627270454eceaf83d7a37fd7e2' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_16_4b82527e04201acf03336d209b9b8b62><input  type=\"checkbox\" name=\"checkbox_16[]\" data-name=\"checkbox_16\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_16_4b82527e04201acf03336d209b9b8b62' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"6. He perdut el coneixement, he tingut mals de cap per migrana, convulsions, accident cerebrovascular, lesi\u00f3 significativa al cap, o he patit de lesi\u00f3 o malaltia neurol\u00f2gica persistent.\">6. He perdut el coneixement, he tingut mals de cap per migrana, convulsions, accident cerebrovascular, lesi\u00f3 significativa al cap, o he patit de lesi\u00f3 o malaltia neurol\u00f2gica persistent.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_17_76feae04c773ff631bb7443b7c73da36><input  type=\"checkbox\" name=\"checkbox_17[]\" data-name=\"checkbox_17\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_17_76feae04c773ff631bb7443b7c73da36' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_17_b536b51393c991cae18561fd923f06b8><input  type=\"checkbox\" name=\"checkbox_17[]\" data-name=\"checkbox_17\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_17_b536b51393c991cae18561fd923f06b8' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc o he tingut: Lesi\u00f3 al cap amb p\u00e8rdua de consci\u00e8ncia en els darrers 5 anys.\">Tinc o he tingut: Lesi\u00f3 al cap amb p\u00e8rdua de consci\u00e8ncia en els darrers 5 anys.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_15_31cd9b0b5697d08c18bfaff0b5bf2329><input  type=\"checkbox\" name=\"checkbox_15[]\" data-name=\"checkbox_15\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_15_31cd9b0b5697d08c18bfaff0b5bf2329' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_15_965dc3d57a1e32f3930514527d942e45><input  type=\"checkbox\" name=\"checkbox_15[]\" data-name=\"checkbox_15\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_15_965dc3d57a1e32f3930514527d942e45' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc o he tingut: Lesions o malalties neurol\u00f2giques persistents.\">Tinc o he tingut: Lesions o malalties neurol\u00f2giques persistents.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_19_a5464f39403af3c46ff835c47f314cd3><input  type=\"checkbox\" name=\"checkbox_19[]\" data-name=\"checkbox_19\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_19_a5464f39403af3c46ff835c47f314cd3' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_19_4b7795a158cb63e824b215b3d71cdf30><input  type=\"checkbox\" name=\"checkbox_19[]\" data-name=\"checkbox_19\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_19_4b7795a158cb63e824b215b3d71cdf30' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc o he tingut: Mals de cap recurrents per migranya en els darrers 12 mesos, o prenc medicament\u00f3s per prevenir-los.\">Tinc o he tingut: Mals de cap recurrents per migranya en els darrers 12 mesos, o prenc medicament\u00f3s per prevenir-los.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_20_39c4aacbd1c1b01207c246ce4cfb8c63><input  type=\"checkbox\" name=\"checkbox_20[]\" data-name=\"checkbox_20\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_20_39c4aacbd1c1b01207c246ce4cfb8c63' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_20_ef97386bf6370d72b3211012235a83de><input  type=\"checkbox\" name=\"checkbox_20[]\" data-name=\"checkbox_20\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_20_ef97386bf6370d72b3211012235a83de' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc o he tingut: Epil\u00e8psia, atacs o convulsions, o prenc medicaments per prevenir-los.\">Tinc o he tingut: Epil\u00e8psia, atacs o convulsions, o prenc medicaments per prevenir-los.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_21_9c5544cd5543a4cd4668f391498df32c><input  type=\"checkbox\" name=\"checkbox_21[]\" data-name=\"checkbox_21\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_21_9c5544cd5543a4cd4668f391498df32c' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_21_763df7be9c67b7859c1fe26803855514><input  type=\"checkbox\" name=\"checkbox_21[]\" data-name=\"checkbox_21\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_21_763df7be9c67b7859c1fe26803855514' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"7. He tingut problemes psicol\u00f2gics, em diagnosticaran una discapacitat d&#039;aprenentatge, trastorn de la personalitat, atacs de p\u00e0nic o addicci\u00f3 a les drogues o l&#039;alcohol.\">7. He tingut problemes psicol\u00f2gics, em diagnosticaran una discapacitat d&#8217;aprenentatge, trastorn de la personalitat, atacs de p\u00e0nic o addicci\u00f3 a les drogues o l&#8217;alcohol.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_27_4690f7a818f2aec77b50031f4a84c21e><input  type=\"checkbox\" name=\"checkbox_27[]\" data-name=\"checkbox_27\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_27_4690f7a818f2aec77b50031f4a84c21e' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_27_de5a4933394f8658f80974a3fe310229><input  type=\"checkbox\" name=\"checkbox_27[]\" data-name=\"checkbox_27\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_27_de5a4933394f8658f80974a3fe310229' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc o he tingut: Salut conductual, problemes mentals o psicol\u00f2gics que requereixin tractament m\u00e8dic o psiqui\u00e0tric.\">Tinc o he tingut: Salut conductual, problemes mentals o psicol\u00f2gics que requereixin tractament m\u00e8dic o psiqui\u00e0tric.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_23_d0d0b8737b6cf59c020c08dd8d0a535b><input  type=\"checkbox\" name=\"checkbox_23[]\" data-name=\"checkbox_23\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_23_d0d0b8737b6cf59c020c08dd8d0a535b' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_23_8069afd78516281e9e57a1954a14ffc7><input  type=\"checkbox\" name=\"checkbox_23[]\" data-name=\"checkbox_23\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_23_8069afd78516281e9e57a1954a14ffc7' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc o he tingut: Depressi\u00f3 Major, tend\u00e8ncia su\u00efcida, atacs de p\u00e0nic, trastorn bipolar descontrolat que requereix medicaci\u00f3\/tractament psicoqu\u00edtric.\">Tinc o he tingut: Depressi\u00f3 Major, tend\u00e8ncia su\u00efcida, atacs de p\u00e0nic, trastorn bipolar descontrolat que requereix medicaci\u00f3\/tractament psicoqu\u00edtric.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_24_8376cbdaaa955b7e53a6a791a64f8474><input  type=\"checkbox\" name=\"checkbox_24[]\" data-name=\"checkbox_24\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_24_8376cbdaaa955b7e53a6a791a64f8474' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_24_952757b2003d644f08d4a6447daebd27><input  type=\"checkbox\" name=\"checkbox_24[]\" data-name=\"checkbox_24\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_24_952757b2003d644f08d4a6447daebd27' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc o he tingut: He estat diagnosticat amb una condici\u00f3 de salut mental o un trastorn daprenentatge o desenvolupament que requereix atenci\u00f3 cont\u00ednua.\">Tinc o he tingut: He estat diagnosticat amb una condici\u00f3 de salut mental o un trastorn daprenentatge o desenvolupament que requereix atenci\u00f3 cont\u00ednua.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_25_3ba8c64c4918fd93b134f4022c70e95f><input  type=\"checkbox\" name=\"checkbox_25[]\" data-name=\"checkbox_25\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_25_3ba8c64c4918fd93b134f4022c70e95f' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_25_88f13b2f7521ec3cfbf7db2ab55b3c79><input  type=\"checkbox\" name=\"checkbox_25[]\" data-name=\"checkbox_25\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_25_88f13b2f7521ec3cfbf7db2ab55b3c79' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc o he tingut: Una addicci\u00f3 a les drogues oa l&#039;alcohol que requereix tractament en els darrers 5 anys.\">Tinc o he tingut: Una addicci\u00f3 a les drogues oa l&#8217;alcohol que requereix tractament en els darrers 5 anys.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_28_9ca653e1a7c5849a83ff8f185b0318a6><input  type=\"checkbox\" name=\"checkbox_28[]\" data-name=\"checkbox_28\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_28_9ca653e1a7c5849a83ff8f185b0318a6' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_28_ec18f1c1285e1ec3fc53aa5bbf1122d3><input  type=\"checkbox\" name=\"checkbox_28[]\" data-name=\"checkbox_28\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_28_ec18f1c1285e1ec3fc53aa5bbf1122d3' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"8. He tingut problemes d&#039;esquena, h\u00e8rnia, \u00falceres o diabetis.\">8. He tingut problemes d&#8217;esquena, h\u00e8rnia, \u00falceres o diabetis.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_22_041be1564aad962c113eba3c1bcea57c><input  type=\"checkbox\" name=\"checkbox_22[]\" data-name=\"checkbox_22\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_22_041be1564aad962c113eba3c1bcea57c' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_22_fa61757b11c5271be1d8cc05e6f9440e><input  type=\"checkbox\" name=\"checkbox_22[]\" data-name=\"checkbox_22\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_22_fa61757b11c5271be1d8cc05e6f9440e' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc o he tingut: Problemes recurrents a l&#039;esquena en els darrers 6 mesos que limiten la meva activitat di\u00e0ria.\">Tinc o he tingut: Problemes recurrents a l&#8217;esquena en els darrers 6 mesos que limiten la meva activitat di\u00e0ria.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_26_fa18ad6435284c2469b6dc7c3f949dc0><input  type=\"checkbox\" name=\"checkbox_26[]\" data-name=\"checkbox_26\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_26_fa18ad6435284c2469b6dc7c3f949dc0' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_26_739897cd279f502e9b7d34362276ed13><input  type=\"checkbox\" name=\"checkbox_26[]\" data-name=\"checkbox_26\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_26_739897cd279f502e9b7d34362276ed13' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc o he tingut: Cirurgia d&#039;esquena o columna vertebral en els darrers 12 mesos.\">Tinc o he tingut: Cirurgia d&#8217;esquena o columna vertebral en els darrers 12 mesos.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_29_ecc4a75ba7d388cfd5a2884fee097d81><input  type=\"checkbox\" name=\"checkbox_29[]\" data-name=\"checkbox_29\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_29_ecc4a75ba7d388cfd5a2884fee097d81' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_29_a6d2063ed7882215c88ad5952f4c6434><input  type=\"checkbox\" name=\"checkbox_29[]\" data-name=\"checkbox_29\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_29_a6d2063ed7882215c88ad5952f4c6434' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc o he tingut: Diabetis, ja sigui controlada per insulina o per dieta, o diabetis gestacional en els darrers 12 mesos.\">Tinc o he tingut: Diabetis, ja sigui controlada per insulina o per dieta, o diabetis gestacional en els darrers 12 mesos.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_30_f2700b983e4327b1c762c85103e77d0b><input  type=\"checkbox\" name=\"checkbox_30[]\" data-name=\"checkbox_30\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_30_f2700b983e4327b1c762c85103e77d0b' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_30_32e430f6defa1a5f2c059f15ec277282><input  type=\"checkbox\" name=\"checkbox_30[]\" data-name=\"checkbox_30\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_30_32e430f6defa1a5f2c059f15ec277282' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc o he tingut: Una h\u00e8rnia no corregida que limita les meves habilitats f\u00edsiques.\">Tinc o he tingut: Una h\u00e8rnia no corregida que limita les meves habilitats f\u00edsiques.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_31_17e28eb355966e67e880e00bc13a81cf><input  type=\"checkbox\" name=\"checkbox_31[]\" data-name=\"checkbox_31\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_31_17e28eb355966e67e880e00bc13a81cf' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_31_f847b073c971fe9a26b21962bdb6bf5e><input  type=\"checkbox\" name=\"checkbox_31[]\" data-name=\"checkbox_31\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_31_f847b073c971fe9a26b21962bdb6bf5e' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc o he tingut: \u00dalceres actives o no tractades, ferides problem\u00e0tiques o cirurgia d&#039;\u00falcers en els darrers 6 mesos.\">Tinc o he tingut: \u00dalceres actives o no tractades, ferides problem\u00e0tiques o cirurgia d&#8217;\u00falcers en els darrers 6 mesos.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_32_0a37a5f80e94a330f9b961664be80078><input  type=\"checkbox\" name=\"checkbox_32[]\" data-name=\"checkbox_32\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_32_0a37a5f80e94a330f9b961664be80078' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_32_27836bb0eeeebaab69d71aaa11dc0c29><input  type=\"checkbox\" name=\"checkbox_32[]\" data-name=\"checkbox_32\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_32_27836bb0eeeebaab69d71aaa11dc0c29' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"9. He tingut problemes estomacals o intestinals, incloent diarrea recent.\">9. He tingut problemes estomacals o intestinals, incloent diarrea recent.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_33_7e628b8b78158b5c30be03b965158737><input  type=\"checkbox\" name=\"checkbox_33[]\" data-name=\"checkbox_33\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_33_7e628b8b78158b5c30be03b965158737' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_33_53811ce05b6a953b55b283af910bb394><input  type=\"checkbox\" name=\"checkbox_33[]\" data-name=\"checkbox_33\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_33_53811ce05b6a953b55b283af910bb394' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc: Cirurgia d&#039;ostomia i no tinc autoritzaci\u00f3 m\u00e8dica per nedar o participar en activitat f\u00edsica.\">Tinc: Cirurgia d&#8217;ostomia i no tinc autoritzaci\u00f3 m\u00e8dica per nedar o participar en activitat f\u00edsica.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_34_09bb10ef86bbf2820a3d454a76f0d2d9><input  type=\"checkbox\" name=\"checkbox_34[]\" data-name=\"checkbox_34\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_34_09bb10ef86bbf2820a3d454a76f0d2d9' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_34_81fa9415da43f16233dae19ac72ce32c><input  type=\"checkbox\" name=\"checkbox_34[]\" data-name=\"checkbox_34\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_34_81fa9415da43f16233dae19ac72ce32c' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc: Deshidrataci\u00f3 que requereix intervenci\u00f3 m\u00e8dica per nedar o participar en activitat f\u00edsica.\">Tinc: Deshidrataci\u00f3 que requereix intervenci\u00f3 m\u00e8dica per nedar o participar en activitat f\u00edsica.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_35_8ed1fabf4fd35ab9c2b3331976e6097b><input  type=\"checkbox\" name=\"checkbox_35[]\" data-name=\"checkbox_35\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_35_8ed1fabf4fd35ab9c2b3331976e6097b' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_35_64b65689b68483e4c4b2a7a9218a228b><input  type=\"checkbox\" name=\"checkbox_35[]\" data-name=\"checkbox_35\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_35_64b65689b68483e4c4b2a7a9218a228b' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc: \u00dalceres estomacals o intestinals actives o no tractades o cirurgia d&#039;\u00falcers en els darrers 6 mesos.\">Tinc: \u00dalceres estomacals o intestinals actives o no tractades o cirurgia d&#8217;\u00falcers en els darrers 6 mesos.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_36_9bf0d0f71618ea6d56b630a98f2ecc22><input  type=\"checkbox\" name=\"checkbox_36[]\" data-name=\"checkbox_36\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_36_9bf0d0f71618ea6d56b630a98f2ecc22' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_36_d3c2c91910048be69900e98375c94df4><input  type=\"checkbox\" name=\"checkbox_36[]\" data-name=\"checkbox_36\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_36_d3c2c91910048be69900e98375c94df4' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc: Ardor d&#039;est\u00f3mac freq\u00fcent, regurgitaci\u00f3 o malaltia per reflux gastroesof\u00e0gic (ERGE).\">Tinc: Ardor d&#8217;est\u00f3mac freq\u00fcent, regurgitaci\u00f3 o malaltia per reflux gastroesof\u00e0gic (ERGE).<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_37_bb836750768891beb8e1ae1e3e7ba39f><input  type=\"checkbox\" name=\"checkbox_37[]\" data-name=\"checkbox_37\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_37_bb836750768891beb8e1ae1e3e7ba39f' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_37_eb4282d88759eefa9076a73632c659e7><input  type=\"checkbox\" name=\"checkbox_37[]\" data-name=\"checkbox_37\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_37_eb4282d88759eefa9076a73632c659e7' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc: Colitis ulcerosa activa o no controlada o malaltia de Crohn.\">Tinc: Colitis ulcerosa activa o no controlada o malaltia de Crohn.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_38_dea1d1d96b8ae8a88536bb1053b26182><input  type=\"checkbox\" name=\"checkbox_38[]\" data-name=\"checkbox_38\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_38_dea1d1d96b8ae8a88536bb1053b26182' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_38_ae1c97626c62ff0cca4fd92fae1d574b><input  type=\"checkbox\" name=\"checkbox_38[]\" data-name=\"checkbox_38\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_38_ae1c97626c62ff0cca4fd92fae1d574b' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Tinc: Cirurgia bari\u00e0trica en els darrers 12 mesos.\">Tinc: Cirurgia bari\u00e0trica en els darrers 12 mesos.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_39_8096907660cd9c1b9501abedba98de45><input  type=\"checkbox\" name=\"checkbox_39[]\" data-name=\"checkbox_39\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_39_8096907660cd9c1b9501abedba98de45' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_39_8c4c577035d737e4cd7277ab7ee50145><input  type=\"checkbox\" name=\"checkbox_39[]\" data-name=\"checkbox_39\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_39_8c4c577035d737e4cd7277ab7ee50145' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_2\" ><p style=\"text-align: left\"><strong>Signatura del Participant<\/strong><\/p>\n<p style=\"text-align: left\">Si va respondre NO a les 10 preguntes anteriors, no cal una avaluaci\u00f3 m\u00e8dica. Si us plau, llegiu i accepteu la declaraci\u00f3 del participant a continuaci\u00f3 amb la data i la seva signatura.<br \/>Declaraci\u00f3 del Participant: He respost totes les preguntes honestament, i entenc que accepto la responsabilitat per qualsevol conseq\u00fc\u00e8ncia resultant de qualsevol pregunta que pugui haver respost inexactament o per no haver revelat qualsevol condici\u00f3 de salut existent o passada.<br \/>Signatura del participant (o, si \u00e9s menor d&#8217;edat, cal la signatura del pare\/tutor del participant.)<\/p><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_1  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Signatura\">Signatura<\/label><\/div><div class='ff-el-input--content'><input type='text' name='signature' class='force-hide'>\n\n<div class=\"fluentform-signature-pad-wrapper\">\n    <canvas id='signature_3' \n            class='fluentform-signature-pad' \n            data-form-id='3'\n            data-pen-color='#333'\n            data-pen-size='2'\n            style='\n                background-color: #ffffff;\n                border: 2px dashed #FF2D00;\n                width: fit-content;\n            '\n            height=\"200\"\n    ><\/canvas>\n\n    <div class=\"ff-el-signature__actions\">\n        <div class='fluentform-signature-pad-actions'>\n            <button type='button' class='fluentform-signature-button fluentform-signature-clear'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 561 561\" xml:space=\"preserve\"><g><g id=\"loop\"><path d=\"M280.5,76.5V0l-102,102l102,102v-76.5c84.15,0,153,68.85,153,153c0,25.5-7.65,51-17.85,71.4l38.25,38.25C471.75,357,484.5,321.3,484.5,280.5C484.5,168.3,392.7,76.5,280.5,76.5z M280.5,433.5c-84.15,0-153-68.85-153-153c0-25.5,7.65-51,17.85-71.4l-38.25-38.25C89.25,204,76.5,239.7,76.5,280.5c0,112.2,91.8,204,204,204V561l102-102l-102-102V433.5z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n            \n            <button type='button' class='fluentform-signature-button fluentform-signature-undo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 497.25 497.25\" xml:space=\"preserve\"><g><g id=\"undo\"><path d=\"M248.625,89.25V0l-127.5,127.5l127.5,127.5V140.25c84.15,0,153,68.85,153,153c0,84.15-68.85,153-153,153c-84.15,0-153-68.85-153-153h-51c0,112.2,91.8,204,204,204s204-91.8,204-204S360.825,89.25,248.625,89.25z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n\n            <button type='button' class='fluentform-signature-button fluentform-signature-redo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 485.212 485.212\" xml:space=\"preserve\"><g><path d=\"M242.607,424.559c-75.252,0-136.468-61.209-136.468-136.465c0-75.252,61.216-136.466,136.468-136.466v90.978l151.629-121.302L242.607,0v90.978c-108.687,0-197.117,88.432-197.117,197.117c0,108.691,88.43,197.118,197.117,197.118c108.687,0,197.114-88.427,197.114-197.118h-60.645C379.077,363.35,317.859,424.559,242.607,424.559z\"\/><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n        <\/div>\n\n        <div class='ff-el-signature__actions-hint fluentform-signature-hint'>Fes la teva Signatura aqu\u00ed<\/div>\n    <\/div>\n<\/div>\n<\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_5\"  class='ff-t-container ff-column-container ff_columns_total_3  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 34%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_2_datetime' aria-label=\"Data\">Data<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Data Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime\" id=\"ff_3_2_datetime\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 34%;'><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 34%;'><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_3\" ><p style=\"text-align: left\"><strong>Si heu respost S\u00cd<\/strong> a les preguntes 3, 5 o 10 anteriors o qualsevol de les preguntes de la p\u00e0gina 2, llegiu i accepteu la declaraci\u00f3 anterior amb la data i la vostra signatura, i <strong>porteu el Formulari d&#8217;Avaluaci\u00f3 del Metge al vostre metge<\/strong>, per a una avaluaci\u00f3 m\u00e8dica. La participaci\u00f3 en un programa d&#8217;entrenament de busseig requereix l&#8217;avaluaci\u00f3 i l&#8217;aprovaci\u00f3 del vostre metge.<\/p><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='Terms and Conditions: He llegit i Accepto el  Av\u00eds Legal i la Pol\u00edtica de Privadesa Contains 2 links. 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inactive\" data-title-link=\"-tab\">\n\t\t\t\t        <div class='fluentform ff-default fluentform_wrapper_4 ffs_default_wrap'><form data-form_id=\"4\" id=\"fluentform_4\" class=\"frm-fluent-form fluent_form_4 ff-el-form-top ff_form_instance_4_3 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_4_3\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Medical Questionnaire &#8211; English<\/legend>        <div\n                style=\"display: none!important; position: absolute!important; transform: translateX(1000%)!important;\"\n                class=\"ff-el-group ff-hpsf-container\"\n        >\n            <div class=\"ff-el-input--label asterisk-right\">\n                <label for=\"ff_4_item_sf\" aria-label=\"Contact\">\n                    Contact                <\/label>\n            <\/div>\n            <div class=\"ff-el-input--content\">\n                <input type=\"text\"\n                       name=\"item_4__fluent_sf\"\n                       class=\"ff-el-form-control\"\n                       id=\"ff_4_item_sf\"\n                \/>\n            <\/div>\n        <\/div>\n        <input type='hidden' name='__fluent_form_embded_post_id' value='37216' \/><input type=\"hidden\" id=\"_fluentform_4_fluentformnonce\" name=\"_fluentform_4_fluentformnonce\" value=\"27024ddcb1\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/ca\/wp-json\/wp\/v2\/pages\/37216\" \/><div data-type=\"name-element\" data-name=\"names_3\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group  ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_3_names_3_first_name_' >Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_3[first_name]\" id=\"ff_4_3_names_3_first_name_\" class=\"ff-el-form-control\" placeholder=\"Name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group  ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_3_names_3_last_name_' >Surname<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_3[last_name]\" id=\"ff_4_3_names_3_last_name_\" class=\"ff-el-form-control\" placeholder=\"Surname\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_3_input_text_10' aria-label=\"DNI\">DNI<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_10\" class=\"ff-el-form-control\" placeholder=\"DNI\" data-name=\"input_text_10\" id=\"ff_4_3_input_text_10\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_3_datetime_2' aria-label=\"Date of birth\">Date of birth<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date of birth Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime_2\" id=\"ff_4_3_datetime_2\" class=\"ff-el-form-control ff-el-datepicker\" placeholder=\"Date of birth\" data-name=\"datetime_2\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_3_email_2' aria-label=\"Email\">Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email_2\" id=\"ff_4_3_email_2\" class=\"ff-el-form-control\" placeholder=\"Email\" data-name=\"email_2\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_3_numeric-field_3' aria-label=\"N\u00famero de Tel\u00e9fono\">N\u00famero de Tel\u00e9fono<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_3\" id=\"ff_4_3_numeric-field_3\" class=\"ff-el-form-control\" placeholder=\"Tel\u00e9fono\" data-name=\"numeric-field_3\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_3_dropdown_1' aria-label=\"Diving level\">Diving level<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_1\" id=\"ff_4_3_dropdown_1\" class=\"ff-el-form-control\" data-name=\"dropdown_1\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\">Select<\/option><option value=\"I have never dived\"  >I have never dived<\/option><option value=\"Beginner\"  >Beginner<\/option><option value=\"Amateur\"  >Amateur<\/option><option value=\"Professional\"  >Professional<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_3_country-list' aria-label=\"Country\">Country<\/label><\/div><div class='ff-el-input--content'><select name=\"country-list\" id=\"ff_4_3_country-list\" class=\"ff-el-form-control\" placeholder=\"Select Country\" data-name=\"country-list\" aria-invalid='false' aria-required=true><option value=''>Select Country<\/option><option value='AF' >Afghanistan<\/option><option value='AX' >Aland Islands<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctica<\/option><option value='AG' >Antigua and Barbuda<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BY' >Belarus<\/option><option value='PW' >Belau<\/option><option value='BE' >Belgium<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Saint Eustatius and Saba<\/option><option value='BA' >Bosnia and Herzegovina<\/option><option value='BW' >Botswana<\/option><option value='BV' >Bouvet Island<\/option><option value='BR' >Brazil<\/option><option value='IO' >British Indian Ocean Territory<\/option><option value='VG' >British Virgin Islands<\/option><option value='BN' >Brunei<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='KH' >Cambodia<\/option><option value='CM' >Cameroon<\/option><option value='CA' >Canada<\/option><option value='CV' >Cape Verde<\/option><option value='KY' >Cayman Islands<\/option><option value='CF' >Central African Republic<\/option><option value='TD' >Chad<\/option><option value='CL' >Chile<\/option><option value='CN' >China<\/option><option value='CX' >Christmas Island<\/option><option value='CC' >Cocos (Keeling) Islands<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comoros<\/option><option value='CK' >Cook Islands<\/option><option value='CR' >Costa Rica<\/option><option value='HR' >Croatia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura&ccedil;ao<\/option><option value='CY' >Cyprus<\/option><option value='CZ' >Czech Republic<\/option><option value='CD' >Democratic Republic of the Congo (Kinshasa)<\/option><option value='DK' >Denmark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominica<\/option><option value='DO' >Dominican Republic<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egypt<\/option><option value='SV' >El Salvador<\/option><option value='GQ' >Equatorial Guinea<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='ET' >Ethiopia<\/option><option value='FK' >Falkland Islands<\/option><option value='FO' >Faroe Islands<\/option><option value='FJ' >Fiji<\/option><option value='FI' >Finland<\/option><option value='FR' >France<\/option><option value='GF' >French Guiana<\/option><option value='PF' >French Polynesia<\/option><option value='TF' >French Southern Territories<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germany<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GR' >Greece<\/option><option value='GL' >Greenland<\/option><option value='GD' >Grenada<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GN' >Guinea<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HM' >Heard Island and McDonald Islands<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hungary<\/option><option value='IS' >Iceland<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Ireland<\/option><option value='IM' >Isle of Man<\/option><option value='IL' >Israel<\/option><option value='IT' >Italy<\/option><option value='CI' >Ivory Coast<\/option><option value='JM' >Jamaica<\/option><option value='JP' >Japan<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordan<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='XK' >Kosovo<\/option><option value='KW' >Kuwait<\/option><option value='KG' >Kyrgyzstan<\/option><option value='LA' >Laos<\/option><option value='LV' >Latvia<\/option><option value='LB' >Lebanon<\/option><option value='LS' >Lesotho<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libya<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lithuania<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao S.A.R., China<\/option><option value='MK' >Macedonia<\/option><option value='MG' >Madagascar<\/option><option value='MW' >Malawi<\/option><option value='MY' >Malaysia<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MH' >Marshall Islands<\/option><option value='MQ' >Martinique<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldova<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MA' >Morocco<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NL' >Netherlands<\/option><option value='NC' >New Caledonia<\/option><option value='NZ' >New Zealand<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NF' >Norfolk Island<\/option><option value='KP' >North Korea<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norway<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PS' >Palestinian Territory<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua New Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Poland<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='QA' >Qatar<\/option><option value='CG' >Republic of the Congo (Brazzaville)<\/option><option value='RE' >Reunion<\/option><option value='RO' >Romania<\/option><option value='RU' >Russia<\/option><option value='RW' >Rwanda<\/option><option value='BL' >Saint Barth&eacute;lemy<\/option><option value='SH' >Saint Helena<\/option><option value='KN' >Saint Kitts and Nevis<\/option><option value='LC' >Saint Lucia<\/option><option value='SX' >Saint Martin (Dutch part)<\/option><option value='MF' >Saint Martin (French part)<\/option><option value='PM' >Saint Pierre and Miquelon<\/option><option value='VC' >Saint Vincent and the Grenadines<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tome and Principe<\/option><option value='SA' >Saudi Arabia<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SK' >Slovakia<\/option><option value='SI' >Slovenia<\/option><option value='SB' >Solomon Islands<\/option><option value='SO' >Somalia<\/option><option value='ZA' >South Africa<\/option><option value='GS' >South Georgia\/Sandwich Islands<\/option><option value='KR' >South Korea<\/option><option value='SS' >South Sudan<\/option><option value='ES' >Spain<\/option><option value='LK' >Sri Lanka<\/option><option value='SD' >Sudan<\/option><option value='SR' >Suriname<\/option><option value='SJ' >Svalbard and Jan Mayen<\/option><option value='SZ' >Swaziland<\/option><option value='SE' >Sweden<\/option><option value='CH' >Switzerland<\/option><option value='SY' >Syria<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzania<\/option><option value='TH' >Thailand<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad and Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >Turkey<\/option><option value='TM' >Turkmenistan<\/option><option value='TC' >Turks and Caicos Islands<\/option><option value='TV' >Tuvalu<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='AE' >United Arab Emirates<\/option><option value='GB' >United Kingdom (UK)<\/option><option value='US' >United States (US)<\/option><option value='UM' >United States (US) Minor Outlying Islands<\/option><option value='VI' >United States (US) Virgin Islands<\/option><option value='UY' >Uruguay<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VA' >Vatican<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='WF' >Wallis and Futuna<\/option><option value='EH' >Western Sahara<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><\/select><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-4_1\" ><p style=\"text-align: left\"><strong>ANNEX I<\/strong><\/p>\n<p style=\"text-align: left\"><strong>Questionnaire on the state of health for the practice of recreational diving<\/strong><\/p>\n<p style=\"text-align: left\">Diving requires good physical and mental health. There are some medical conditions that can be dangerous while diving, listed below. Those who have or are predisposed to any of these conditions should be evaluated by a doctor. This Diver&#8217;s Medical Questionnaire provides a basis for determining if you should seek such an assessment. If you have any concerns about your fitness to dive and they are not represented on this form, please consult your physician before diving. References to \u201cdiving\u201d in this form include both recreational scuba diving and breath-hold diving. This form is designed primarily as an initial medical exam for new divers, but is also appropriate for divers undergoing continuing education. For your safety and the safety of others who may dive with you, answer all questions honestly.<\/p>\n<p style=\"text-align: left\"><strong>INSTRUCTIONS<\/strong><\/p>\n<p style=\"text-align: left\">Complete this questionnaire as a prerequisite for freediving or scuba training.<br \/>Note to women: If you are pregnant, or trying to become pregnant,<strong> do not dive.<\/strong><\/p><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Medical certificate\">Medical certificate<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_eac2f9f379ced7954429233387c60de2><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes, i have a certificate\"  id='checkbox_eac2f9f379ced7954429233387c60de2' aria-label='Yes, i have a certificate' aria-invalid='false' aria-required=true> <span>Yes, i have a certificate<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_81112558cac82a281fb02a8603d81bab><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No, i do not have a certificate\"  id='checkbox_81112558cac82a281fb02a8603d81bab' aria-label='No, i do not have a certificate' aria-invalid='false' aria-required=true> <span>No, i do not have a certificate<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"1. I have had problems with my lungs or breathing, heart, or blood.\">1. I have had problems with my lungs or breathing, heart, or blood.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_40_ef0df9a42b1c2f0358ad2a2493b05a5a><input  type=\"checkbox\" name=\"checkbox_40[]\" data-name=\"checkbox_40\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_40_ef0df9a42b1c2f0358ad2a2493b05a5a' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_40_795b34c99db7d0464184285c925f7257><input  type=\"checkbox\" name=\"checkbox_40[]\" data-name=\"checkbox_40\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_40_795b34c99db7d0464184285c925f7257' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I have or have had: Thoracic surgery, heart surgery, heart valve surgery, stent placement, or pneumothorax (collapsed lung).\">I have or have had: Thoracic surgery, heart surgery, heart valve surgery, stent placement, or pneumothorax (collapsed lung).<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_3_84f1a627d45b3fa8477dfaa28a2074cb><input  type=\"checkbox\" name=\"checkbox_3[]\" data-name=\"checkbox_3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_3_84f1a627d45b3fa8477dfaa28a2074cb' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_3_cbfac7bbc01c44aebf2c334f3963e8b1><input  type=\"checkbox\" name=\"checkbox_3[]\" data-name=\"checkbox_3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_3_cbfac7bbc01c44aebf2c334f3963e8b1' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I have or have had: Asthma, wheezing, severe allergies, hay fever, or congested airways in the last 12 months that limits my physical activity or exercise.\">I have or have had: Asthma, wheezing, severe allergies, hay fever, or congested airways in the last 12 months that limits my physical activity or exercise.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_4_a94a076d8bba8022dc092421da234649><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_4_a94a076d8bba8022dc092421da234649' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_4_d80dfce943ae3d5ce554bbddade0abab><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_4_d80dfce943ae3d5ce554bbddade0abab' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I have or have had: A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, pulmonary edema, cardiomyopathy, or stroke, or I am taking medication for any heart condition.\">I have or have had: A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, pulmonary edema, cardiomyopathy, or stroke, or I am taking medication for any heart condition.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_5_c19db7d4774c5e75d17b9bd722e32445><input  type=\"checkbox\" name=\"checkbox_5[]\" data-name=\"checkbox_5\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_5_c19db7d4774c5e75d17b9bd722e32445' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_5_19d50547e5931332686a7958a982ce4a><input  type=\"checkbox\" name=\"checkbox_5[]\" data-name=\"checkbox_5\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_5_19d50547e5931332686a7958a982ce4a' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I have or have had: Recurrent bronchitis and persistent cough in the last 12 months, or have been diagnosed with emphysema.\">I have or have had: Recurrent bronchitis and persistent cough in the last 12 months, or have been diagnosed with emphysema.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_6_1ca7aab69cbfe5251ae06962d33af58b><input  type=\"checkbox\" name=\"checkbox_6[]\" data-name=\"checkbox_6\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_6_1ca7aab69cbfe5251ae06962d33af58b' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_6_6d4404f45aeaf6f3044ed35f0e027403><input  type=\"checkbox\" name=\"checkbox_6[]\" data-name=\"checkbox_6\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_6_6d4404f45aeaf6f3044ed35f0e027403' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"2. I am over 45 years old\">2. I am over 45 years old<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_1_198a8b76c12316ba1efa1e6dc814d614><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_1_198a8b76c12316ba1efa1e6dc814d614' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_1_46a385666eead1ba38e6a116cdad261c><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_1_46a385666eead1ba38e6a116cdad261c' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I am over 45 years old and: I currently smoke or inhale nicotine by other means\">I am over 45 years old and: I currently smoke or inhale nicotine by other means<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_7_4e9783d88bc5c1bd33b5aff197938356><input  type=\"checkbox\" name=\"checkbox_7[]\" data-name=\"checkbox_7\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_7_4e9783d88bc5c1bd33b5aff197938356' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_7_1e505ad38473d0c66fa4f2aace227478><input  type=\"checkbox\" name=\"checkbox_7[]\" data-name=\"checkbox_7\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_7_1e505ad38473d0c66fa4f2aace227478' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I am over 45 years old and: I currently smoke or I am over 45 years old and: I have high cholesterol.nicotine by other means\">I am over 45 years old and: I currently smoke or I am over 45 years old and: I have high cholesterol.nicotine by other means<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_8_0238881508ab1afbf5d30882fbf17c2b><input  type=\"checkbox\" name=\"checkbox_8[]\" data-name=\"checkbox_8\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_8_0238881508ab1afbf5d30882fbf17c2b' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_8_803d7c49b45916822684b824e2f5f272><input  type=\"checkbox\" name=\"checkbox_8[]\" data-name=\"checkbox_8\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_8_803d7c49b45916822684b824e2f5f272' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I am over 45 years old and: I have high blood pressure\">I am over 45 years old and: I have high blood pressure<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_10_1b3bd1965d1554c9901ca7fc98358f24><input  type=\"checkbox\" name=\"checkbox_10[]\" data-name=\"checkbox_10\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_10_1b3bd1965d1554c9901ca7fc98358f24' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_10_4be01cb238dbf755d4dc042ebdb22cfb><input  type=\"checkbox\" name=\"checkbox_10[]\" data-name=\"checkbox_10\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_10_4be01cb238dbf755d4dc042ebdb22cfb' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I am over 45 years old and: I have had a relative (1st or 2nd degree consanguinity) who died of sudden death or from heart disease or stroke before the age of 50, or I have a family history of heart disease before the Age 50 (including abnormal heart rhythms, coronary artery disease, or cardiomyopathy)\">I am over 45 years old and: I have had a relative (1st or 2nd degree consanguinity) who died of sudden death or from heart disease or stroke before the age of 50, or I have a family history of heart disease before the Age 50 (including abnormal heart rhythms, coronary artery disease, or cardiomyopathy)<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_9_78ca6929a11300526536c2884c8644ef><input  type=\"checkbox\" name=\"checkbox_9[]\" data-name=\"checkbox_9\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_9_78ca6929a11300526536c2884c8644ef' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_9_fd72d4d1aa12bcc98c161e584b9784b7><input  type=\"checkbox\" name=\"checkbox_9[]\" data-name=\"checkbox_9\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_9_fd72d4d1aa12bcc98c161e584b9784b7' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"3. It is difficult for me to engage in moderate exercise (for example, walking 1.6 kilometers in 12 minutes or swimming 200 meters without resting), or I have not been able to participate in normal physical activity due to fitness or health reasons in the last 12 months.\">3. It is difficult for me to engage in moderate exercise (for example, walking 1.6 kilometers in 12 minutes or swimming 200 meters without resting), or I have not been able to participate in normal physical activity due to fitness or health reasons in the last 12 months.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_2_f4a4855bb6d429d4a654a38bb7e159e7><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_2_f4a4855bb6d429d4a654a38bb7e159e7' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_2_6bdf227e4bcab9292f47ec47c73a6f04><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_2_6bdf227e4bcab9292f47ec47c73a6f04' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"4. I have had problems with my eyes, ears, and nasal passages or sinuses.\">4. I have had problems with my eyes, ears, and nasal passages or sinuses.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_12_5100e5c987c20ffbd0caf46730b8c3e8><input  type=\"checkbox\" name=\"checkbox_12[]\" data-name=\"checkbox_12\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_12_5100e5c987c20ffbd0caf46730b8c3e8' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_12_12f3a36a31741190f1c49baad48bc961><input  type=\"checkbox\" name=\"checkbox_12[]\" data-name=\"checkbox_12\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_12_12f3a36a31741190f1c49baad48bc961' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I have or have had: Sinus surgery in the last 6 months.\">I have or have had: Sinus surgery in the last 6 months.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_13_1b557b385d8764b75c566970d4e88dd8><input  type=\"checkbox\" name=\"checkbox_13[]\" data-name=\"checkbox_13\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_13_1b557b385d8764b75c566970d4e88dd8' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_13_e234f6642808d9cf7f667cf7337046e1><input  type=\"checkbox\" name=\"checkbox_13[]\" data-name=\"checkbox_13\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_13_e234f6642808d9cf7f667cf7337046e1' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I have or have had: Ear diseases or ear surgery, hearing loss or balance disorders.\">I have or have had: Ear diseases or ear surgery, hearing loss or balance disorders.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_11_894b074503a814191c106bbdac4bf451><input  type=\"checkbox\" name=\"checkbox_11[]\" data-name=\"checkbox_11\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_11_894b074503a814191c106bbdac4bf451' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_11_6ae9311943a8e1a4cfbbdb9100ab8457><input  type=\"checkbox\" name=\"checkbox_11[]\" data-name=\"checkbox_11\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_11_6ae9311943a8e1a4cfbbdb9100ab8457' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I have or have had: Recurrent sinusitis in the last 12 months.\">I have or have had: Recurrent sinusitis in the last 12 months.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_14_35119391b55535d55c6e49ea4a3e938c><input  type=\"checkbox\" name=\"checkbox_14[]\" data-name=\"checkbox_14\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_14_35119391b55535d55c6e49ea4a3e938c' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_14_c0a4e7704e5b4654d040efb93434803f><input  type=\"checkbox\" name=\"checkbox_14[]\" data-name=\"checkbox_14\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_14_c0a4e7704e5b4654d040efb93434803f' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I have or have had: Occult surgery in the last 3 months.\">I have or have had: Occult surgery in the last 3 months.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_18_3b156552016527982036b225f03d8934><input  type=\"checkbox\" name=\"checkbox_18[]\" data-name=\"checkbox_18\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_18_3b156552016527982036b225f03d8934' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_18_f810344a4b7f3ba766de1f335f3c1671><input  type=\"checkbox\" name=\"checkbox_18[]\" data-name=\"checkbox_18\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_18_f810344a4b7f3ba766de1f335f3c1671' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"5. I have had surgery in the last 12 months, or have ongoing problems related to previous surgery.\">5. I have had surgery in the last 12 months, or have ongoing problems related to previous surgery.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_16_b0c4aa3d15cd5361aaab4350602f5d4c><input  type=\"checkbox\" name=\"checkbox_16[]\" data-name=\"checkbox_16\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_16_b0c4aa3d15cd5361aaab4350602f5d4c' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_16_e3f4b868330623191673fbdfd1baab08><input  type=\"checkbox\" name=\"checkbox_16[]\" data-name=\"checkbox_16\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_16_e3f4b868330623191673fbdfd1baab08' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or sustained neurological injury or disease.\">6. I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or sustained neurological injury or disease.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_17_1414c75f4445585694356cebb5bd2bf6><input  type=\"checkbox\" name=\"checkbox_17[]\" data-name=\"checkbox_17\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_17_1414c75f4445585694356cebb5bd2bf6' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_17_c38aad885721587ece758c49e7b3a011><input  type=\"checkbox\" name=\"checkbox_17[]\" data-name=\"checkbox_17\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_17_c38aad885721587ece758c49e7b3a011' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I have or have had: Head injury with loss of consciousness in the last 5 years.\">I have or have had: Head injury with loss of consciousness in the last 5 years.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_15_d1fe65b1aa9a9704713d34e36576063c><input  type=\"checkbox\" name=\"checkbox_15[]\" data-name=\"checkbox_15\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_15_d1fe65b1aa9a9704713d34e36576063c' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_15_c5b99f9a10871a4369e9762448573ec9><input  type=\"checkbox\" name=\"checkbox_15[]\" data-name=\"checkbox_15\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_15_c5b99f9a10871a4369e9762448573ec9' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I have or have had: Persistent neurological injuries or illnesses.\">I have or have had: Persistent neurological injuries or illnesses.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_19_43f1268f618f3a01df2000947a04cdd6><input  type=\"checkbox\" name=\"checkbox_19[]\" data-name=\"checkbox_19\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_19_43f1268f618f3a01df2000947a04cdd6' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_19_404c97f8596ef7ad69e4ec99294cd05c><input  type=\"checkbox\" name=\"checkbox_19[]\" data-name=\"checkbox_19\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_19_404c97f8596ef7ad69e4ec99294cd05c' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I have or have had: Recurring migraine headaches in the past 12 months, or I take medication to prevent them.\">I have or have had: Recurring migraine headaches in the past 12 months, or I take medication to prevent them.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_20_d557090aa1fc90d91f257623016a500b><input  type=\"checkbox\" name=\"checkbox_20[]\" data-name=\"checkbox_20\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_20_d557090aa1fc90d91f257623016a500b' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_20_67100246bb1b304d77d736ee8b16c218><input  type=\"checkbox\" name=\"checkbox_20[]\" data-name=\"checkbox_20\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_20_67100246bb1b304d77d736ee8b16c218' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I have or have had: Epilepsy, fits or convulsions, or I take medicine to prevent them.\">I have or have had: Epilepsy, fits or convulsions, or I take medicine to prevent them.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_21_843a6e45e5aa81b8d7f9df6c1bfb6021><input  type=\"checkbox\" name=\"checkbox_21[]\" data-name=\"checkbox_21\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_21_843a6e45e5aa81b8d7f9df6c1bfb6021' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_21_f68ef6adcadd5d3ef38e9bff5183a094><input  type=\"checkbox\" name=\"checkbox_21[]\" data-name=\"checkbox_21\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_21_f68ef6adcadd5d3ef38e9bff5183a094' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"7. I have had psychological problems, been diagnosed with a learning disability, personality disorder, panic attacks, or an addiction to drugs or alcohol.\">7. I have had psychological problems, been diagnosed with a learning disability, personality disorder, panic attacks, or an addiction to drugs or alcohol.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_27_72dd0d0e2cee36fabc1a3da97eab26f3><input  type=\"checkbox\" name=\"checkbox_27[]\" data-name=\"checkbox_27\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_27_72dd0d0e2cee36fabc1a3da97eab26f3' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_27_ac14c27ab2b45271ba63cb42bd436204><input  type=\"checkbox\" name=\"checkbox_27[]\" data-name=\"checkbox_27\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_27_ac14c27ab2b45271ba63cb42bd436204' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I have or have had: Behavioral health, mental or psychological problems that require medical or psychiatric treatment.\">I have or have had: Behavioral health, mental or psychological problems that require medical or psychiatric treatment.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_23_d26c7521d6ce2d902024061da27ca82e><input  type=\"checkbox\" name=\"checkbox_23[]\" data-name=\"checkbox_23\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_23_d26c7521d6ce2d902024061da27ca82e' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_23_c31d34c62ab7f1ef2736d0b1874aafad><input  type=\"checkbox\" name=\"checkbox_23[]\" data-name=\"checkbox_23\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_23_c31d34c62ab7f1ef2736d0b1874aafad' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I have or have had: Major Depression, suicidal tendency, panic attacks, uncontrolled bipolar disorder that requires medication\/psychiatric treatment.\">I have or have had: Major Depression, suicidal tendency, panic attacks, uncontrolled bipolar disorder that requires medication\/psychiatric treatment.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_24_632d1bba0a46f73d61b3f99ae557065f><input  type=\"checkbox\" name=\"checkbox_24[]\" data-name=\"checkbox_24\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_24_632d1bba0a46f73d61b3f99ae557065f' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_24_4e91cb840ab675ba78f25232026e4e63><input  type=\"checkbox\" name=\"checkbox_24[]\" data-name=\"checkbox_24\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_24_4e91cb840ab675ba78f25232026e4e63' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I have or have had: I have been diagnosed with a mental health condition or a learning or developmental disorder that requires ongoing care.\">I have or have had: I have been diagnosed with a mental health condition or a learning or developmental disorder that requires ongoing care.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_25_efddc42bd7a4609c1b3e54c32262dd82><input  type=\"checkbox\" name=\"checkbox_25[]\" data-name=\"checkbox_25\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_25_efddc42bd7a4609c1b3e54c32262dd82' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_25_37332307521336336408a5cccad4f9a6><input  type=\"checkbox\" name=\"checkbox_25[]\" data-name=\"checkbox_25\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_25_37332307521336336408a5cccad4f9a6' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I have or have had: A drug or alcohol addiction that requires treatment in the last 5 years.\">I have or have had: A drug or alcohol addiction that requires treatment in the last 5 years.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_28_109d2f75ec3806452c1e372d2a8133de><input  type=\"checkbox\" name=\"checkbox_28[]\" data-name=\"checkbox_28\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_28_109d2f75ec3806452c1e372d2a8133de' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_28_9d9886eb3d6760b5ebcf335984a5d167><input  type=\"checkbox\" name=\"checkbox_28[]\" data-name=\"checkbox_28\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_28_9d9886eb3d6760b5ebcf335984a5d167' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"8. I have had back problems, hernia, ulcers or diabetes.\">8. I have had back problems, hernia, ulcers or diabetes.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_22_448c33ea702647890e290c30d322839e><input  type=\"checkbox\" name=\"checkbox_22[]\" data-name=\"checkbox_22\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_22_448c33ea702647890e290c30d322839e' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_22_680dcaf37bb597e3dd369786d732e474><input  type=\"checkbox\" name=\"checkbox_22[]\" data-name=\"checkbox_22\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_22_680dcaf37bb597e3dd369786d732e474' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I have or have had: Recurring back problems in the last 6 months that limit my daily activity.\">I have or have had: Recurring back problems in the last 6 months that limit my daily activity.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_26_8d69b62a4d4d9a5da99a12498b00d935><input  type=\"checkbox\" name=\"checkbox_26[]\" data-name=\"checkbox_26\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_26_8d69b62a4d4d9a5da99a12498b00d935' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_26_3f9a2a56bfd2a77c7d74e2342a7a7295><input  type=\"checkbox\" name=\"checkbox_26[]\" data-name=\"checkbox_26\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_26_3f9a2a56bfd2a77c7d74e2342a7a7295' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I have or have had: Back or spine surgery in the last 12 months.\">I have or have had: Back or spine surgery in the last 12 months.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_29_c88df1beaf7ccb27448709dc3dda7163><input  type=\"checkbox\" name=\"checkbox_29[]\" data-name=\"checkbox_29\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_29_c88df1beaf7ccb27448709dc3dda7163' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_29_87e89c9f52d7292d4552bf660ed92831><input  type=\"checkbox\" name=\"checkbox_29[]\" data-name=\"checkbox_29\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_29_87e89c9f52d7292d4552bf660ed92831' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I have or have had: Diabetes, either controlled by insulin or diet, or gestational diabetes in the last 12 months.\">I have or have had: Diabetes, either controlled by insulin or diet, or gestational diabetes in the last 12 months.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_30_d1aa56f4ae2601576d4e4e8cd98ceebb><input  type=\"checkbox\" name=\"checkbox_30[]\" data-name=\"checkbox_30\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_30_d1aa56f4ae2601576d4e4e8cd98ceebb' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_30_eebd17e4c568a9e53b6bbf3b08cd322a><input  type=\"checkbox\" name=\"checkbox_30[]\" data-name=\"checkbox_30\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_30_eebd17e4c568a9e53b6bbf3b08cd322a' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I have or have had: An uncorrected hernia that limits my physical abilities.\">I have or have had: An uncorrected hernia that limits my physical abilities.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_31_ca686192ecbd0e886c7330a49b66a65d><input  type=\"checkbox\" name=\"checkbox_31[]\" data-name=\"checkbox_31\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_31_ca686192ecbd0e886c7330a49b66a65d' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_31_77e83170acae4f70e466bf77f493df64><input  type=\"checkbox\" name=\"checkbox_31[]\" data-name=\"checkbox_31\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_31_77e83170acae4f70e466bf77f493df64' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I have or have had: Active or untreated ulcers, problem wounds, or ulcer surgery in the last 6 months.\">I have or have had: Active or untreated ulcers, problem wounds, or ulcer surgery in the last 6 months.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_32_f3ce74c96b68f54612dec169177e8e34><input  type=\"checkbox\" name=\"checkbox_32[]\" data-name=\"checkbox_32\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_32_f3ce74c96b68f54612dec169177e8e34' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_32_1b4a3610004ef5c9d4f14c2ce1f6c3ca><input  type=\"checkbox\" name=\"checkbox_32[]\" data-name=\"checkbox_32\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_32_1b4a3610004ef5c9d4f14c2ce1f6c3ca' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"9. I have had stomach or intestinal problems, including recent diarrhea.\">9. I have had stomach or intestinal problems, including recent diarrhea.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_33_1d631f0360612311edd0057a25419cd3><input  type=\"checkbox\" name=\"checkbox_33[]\" data-name=\"checkbox_33\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_33_1d631f0360612311edd0057a25419cd3' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_33_f444c9201a9bc68e2e4e8e81d4ea56ea><input  type=\"checkbox\" name=\"checkbox_33[]\" data-name=\"checkbox_33\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_33_f444c9201a9bc68e2e4e8e81d4ea56ea' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I have: Ostomy surgery and I am not medically cleared to swim or engage in physical activity.\">I have: Ostomy surgery and I am not medically cleared to swim or engage in physical activity.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_34_623795f3257cb07238f027afe8cac9b9><input  type=\"checkbox\" name=\"checkbox_34[]\" data-name=\"checkbox_34\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_34_623795f3257cb07238f027afe8cac9b9' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_34_82373723160fb0cd90f66ca0fb97cb3b><input  type=\"checkbox\" name=\"checkbox_34[]\" data-name=\"checkbox_34\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_34_82373723160fb0cd90f66ca0fb97cb3b' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I have: Dehydration requiring medical intervention to swim or participate in physical activity.\">I have: Dehydration requiring medical intervention to swim or participate in physical activity.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_35_923b48786e6817f579e841537612db3e><input  type=\"checkbox\" name=\"checkbox_35[]\" data-name=\"checkbox_35\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_35_923b48786e6817f579e841537612db3e' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_35_50c8a0eda13fd2f5456bb13ebf51bb0a><input  type=\"checkbox\" name=\"checkbox_35[]\" data-name=\"checkbox_35\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_35_50c8a0eda13fd2f5456bb13ebf51bb0a' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I have: Active or untreated stomach or intestinal ulcers or ulcer surgery in the last 6 months.\">I have: Active or untreated stomach or intestinal ulcers or ulcer surgery in the last 6 months.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_36_29c16d4b0d2a783208718f5bf9046b14><input  type=\"checkbox\" name=\"checkbox_36[]\" data-name=\"checkbox_36\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_36_29c16d4b0d2a783208718f5bf9046b14' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_36_0c76755ac34343b0de7ba13d0f7bf270><input  type=\"checkbox\" name=\"checkbox_36[]\" data-name=\"checkbox_36\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_36_0c76755ac34343b0de7ba13d0f7bf270' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I have: Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).\">I have: Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_37_d449825aaf66f463f29522b12505c452><input  type=\"checkbox\" name=\"checkbox_37[]\" data-name=\"checkbox_37\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_37_d449825aaf66f463f29522b12505c452' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_37_08b2ae1ad8d3cb4d5149866bcd65472c><input  type=\"checkbox\" name=\"checkbox_37[]\" data-name=\"checkbox_37\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_37_08b2ae1ad8d3cb4d5149866bcd65472c' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I have: Active or uncontrolled ulcerative colitis or Crohn&#039;s disease.\">I have: Active or uncontrolled ulcerative colitis or Crohn&#8217;s disease.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_38_8996be74d0d5d917c23d95bb789820c0><input  type=\"checkbox\" name=\"checkbox_38[]\" data-name=\"checkbox_38\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_38_8996be74d0d5d917c23d95bb789820c0' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_38_decfd48df8538533ab12982065f08d9f><input  type=\"checkbox\" name=\"checkbox_38[]\" data-name=\"checkbox_38\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_38_decfd48df8538533ab12982065f08d9f' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"I have: Bariatric surgery in the last 12 months.\">I have: Bariatric surgery in the last 12 months.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_39_0653a9c1fdd75ddad6c6e493a52fb69a><input  type=\"checkbox\" name=\"checkbox_39[]\" data-name=\"checkbox_39\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_39_0653a9c1fdd75ddad6c6e493a52fb69a' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_39_ba6a308c0b189a7a24c570c6d5285149><input  type=\"checkbox\" name=\"checkbox_39[]\" data-name=\"checkbox_39\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_39_ba6a308c0b189a7a24c570c6d5285149' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-4_2\" ><p style=\"text-align: left\"><strong>Participant Signature<\/strong><\/p>\n<p style=\"text-align: left\">If you answered NO to the 10 questions above, a medical evaluation is not required. Please read and agree to the signed and dated Participant Statement below.<br \/>Participant Statement: I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or from failure to disclose any existing or past health conditions.<br \/>Signature of participant (or, if a minor, the signature of the participant&#8217;s parent\/guardian is required.)<\/p><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_1  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Signature\">Signature<\/label><\/div><div class='ff-el-input--content'><input type='text' name='signature' class='force-hide'>\n\n<div class=\"fluentform-signature-pad-wrapper\">\n    <canvas id='signature_4' \n            class='fluentform-signature-pad' \n            data-form-id='4'\n            data-pen-color='#333'\n            data-pen-size='2'\n            style='\n                background-color: #ffffff;\n                border: 2px dashed #FF2D00;\n                width: fit-content;\n            '\n            height=\"200\"\n    ><\/canvas>\n\n    <div class=\"ff-el-signature__actions\">\n        <div class='fluentform-signature-pad-actions'>\n            <button type='button' class='fluentform-signature-button fluentform-signature-clear'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 561 561\" xml:space=\"preserve\"><g><g id=\"loop\"><path d=\"M280.5,76.5V0l-102,102l102,102v-76.5c84.15,0,153,68.85,153,153c0,25.5-7.65,51-17.85,71.4l38.25,38.25C471.75,357,484.5,321.3,484.5,280.5C484.5,168.3,392.7,76.5,280.5,76.5z M280.5,433.5c-84.15,0-153-68.85-153-153c0-25.5,7.65-51,17.85-71.4l-38.25-38.25C89.25,204,76.5,239.7,76.5,280.5c0,112.2,91.8,204,204,204V561l102-102l-102-102V433.5z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n            \n            <button type='button' class='fluentform-signature-button fluentform-signature-undo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 497.25 497.25\" xml:space=\"preserve\"><g><g id=\"undo\"><path d=\"M248.625,89.25V0l-127.5,127.5l127.5,127.5V140.25c84.15,0,153,68.85,153,153c0,84.15-68.85,153-153,153c-84.15,0-153-68.85-153-153h-51c0,112.2,91.8,204,204,204s204-91.8,204-204S360.825,89.25,248.625,89.25z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n\n            <button type='button' class='fluentform-signature-button fluentform-signature-redo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 485.212 485.212\" xml:space=\"preserve\"><g><path d=\"M242.607,424.559c-75.252,0-136.468-61.209-136.468-136.465c0-75.252,61.216-136.466,136.468-136.466v90.978l151.629-121.302L242.607,0v90.978c-108.687,0-197.117,88.432-197.117,197.117c0,108.691,88.43,197.118,197.117,197.118c108.687,0,197.114-88.427,197.114-197.118h-60.645C379.077,363.35,317.859,424.559,242.607,424.559z\"\/><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n        <\/div>\n\n        <div class='ff-el-signature__actions-hint fluentform-signature-hint'>Sign here<\/div>\n    <\/div>\n<\/div>\n<\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_5\"  class='ff-t-container ff-column-container ff_columns_total_3  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 34%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_4_3_datetime' aria-label=\"Date\">Date<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime\" id=\"ff_4_3_datetime\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 34%;'><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 34%;'><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-4_3\" ><p style=\"text-align: left\"><strong>If you answered YES<\/strong> to questions 3, 5, or 10 above or to any of the questions on page 2, please read and agree to the above signed and dated statement and <strong>take the Physician Evaluation Form to your physician for evaluation<\/strong>. medical. Participation in a diving training program requires the evaluation and approval of your physician.<\/p><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='Terms and Conditions: I have read and I accept the  Legal Notice and the Privacy Policy Contains 2 links. Use tab navigation to review.' class='ff-el-form-check-label ff_tc_label' for=gdpr-agreement_f74102af3567dcddd9901a45e2c9be69><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"gdpr-agreement\" class=\"ff-el-form-check-input ff_gdpr_field\" data-name=\"gdpr-agreement\" id=\"gdpr-agreement_f74102af3567dcddd9901a45e2c9be69\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'>I have read and I accept the <a href=\"https:\/\/palamosdivecenter.com\/aviso-legal\"> Legal Notice<\/a> and the <a href=\"https:\/\/webnova.palamosdivecenter.com\/politica-privacidad\">Privacy Policy<\/a><\/div><\/label><\/div><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='I consent to this website storing my submitted information so that they can respond to my query' class='ff-el-form-check-label ff_tc_label' for=gdpr-agreement_1_cb831100799deee5b5284ff5cd178ffd><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"gdpr-agreement_1\" class=\"ff-el-form-check-input ff_gdpr_field\" data-name=\"gdpr-agreement_1\" id=\"gdpr-agreement_1_cb831100799deee5b5284ff5cd178ffd\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'>I consent to this website storing my submitted information so that they can respond to my query<\/div><\/label><\/div><\/div><div class='ff-el-group ff-text-center ff_submit_btn_wrapper'><button type=\"submit\" class=\"ff-btn ff-btn-submit ff-btn-md ff_btn_style\" >Send form<\/button><\/div><\/fieldset><\/form><div id='fluentform_4_errors' class='ff-errors-in-stack ff_form_instance_4_3 ff-form-loading_errors ff_form_instance_4_3_errors'><\/div><\/div>        <script type=\"text\/javascript\">\n            window.fluent_form_ff_form_instance_4_3 = {\"id\":\"4\",\"settings\":{\"layout\":{\"labelPlacement\":\"top\",\"helpMessagePlacement\":\"with_label\",\"errorMessagePlacement\":\"inline\",\"cssClassName\":\"\"},\"restrictions\":{\"denyEmptySubmission\":{\"enabled\":false}}},\"form_instance\":\"ff_form_instance_4_3\",\"form_id_selector\":\"fluentform_4\",\"rules\":{\"names_3[first_name]\":{\"required\":{\"value\":true,\"message\":\"Required field\"}},\"names_3[middle_name]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"names_3[last_name]\":{\"required\":{\"value\":true,\"message\":\"Required field\"}},\"input_text_10\":{\"required\":{\"value\":true,\"message\":\"Required field\"}},\"datetime_2\":{\"required\":{\"value\":true,\"message\":\"Required field\"}},\"email_2\":{\"required\":{\"value\":true,\"message\":\"Required field\"},\"email\":{\"value\":true,\"message\":\"This field must contain a valid email\"}},\"numeric-field_3\":{\"required\":{\"value\":true,\"message\":\"Required 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inactive\" data-title-link=\"-tab\">\n\t\t\t\t        <div class='fluentform ff-default fluentform_wrapper_5 ffs_default_wrap'><form data-form_id=\"5\" id=\"fluentform_5\" class=\"frm-fluent-form fluent_form_5 ff-el-form-top ff_form_instance_5_4 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_5_4\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Questionnaire m\u00e9dical &#8211; Fran\u00e7ais<\/legend>        <div\n                style=\"display: none!important; position: absolute!important; transform: translateX(1000%)!important;\"\n                class=\"ff-el-group ff-hpsf-container\"\n        >\n            <div class=\"ff-el-input--label asterisk-right\">\n                <label for=\"ff_5_item_sf\" aria-label=\"Contact\">\n                    Contact                <\/label>\n            <\/div>\n            <div class=\"ff-el-input--content\">\n                <input type=\"text\"\n                       name=\"item_5__fluent_sf\"\n                       class=\"ff-el-form-control\"\n                       id=\"ff_5_item_sf\"\n                \/>\n            <\/div>\n        <\/div>\n        <input type='hidden' name='__fluent_form_embded_post_id' value='37216' \/><input type=\"hidden\" id=\"_fluentform_5_fluentformnonce\" name=\"_fluentform_5_fluentformnonce\" value=\"27024ddcb1\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/ca\/wp-json\/wp\/v2\/pages\/37216\" \/><div data-type=\"name-element\" data-name=\"names_3\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group  ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_4_names_3_first_name_' >Nom<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_3[first_name]\" id=\"ff_5_4_names_3_first_name_\" class=\"ff-el-form-control\" placeholder=\"Nom\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group  ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_4_names_3_last_name_' >Noms de familie<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_3[last_name]\" id=\"ff_5_4_names_3_last_name_\" class=\"ff-el-form-control\" placeholder=\"Noms de familie\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_4_input_text_10' aria-label=\"DNI\">DNI<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_10\" class=\"ff-el-form-control\" placeholder=\"DNI\" data-name=\"input_text_10\" id=\"ff_5_4_input_text_10\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_4_datetime_2' aria-label=\"Date de naissance\">Date de naissance<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date de naissance Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime_2\" id=\"ff_5_4_datetime_2\" class=\"ff-el-form-control ff-el-datepicker\" placeholder=\"Date de naissance\" data-name=\"datetime_2\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_4_email_2' aria-label=\"Courrier \u00e9lectronique\">Courrier \u00e9lectronique<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email_2\" id=\"ff_5_4_email_2\" class=\"ff-el-form-control\" placeholder=\"Courrier \u00e9lectronique\" data-name=\"email_2\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_4_numeric-field_3' aria-label=\"Num\u00e9ro de t\u00e9l\u00e9phone\">Num\u00e9ro de t\u00e9l\u00e9phone<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_3\" id=\"ff_5_4_numeric-field_3\" class=\"ff-el-form-control\" placeholder=\"Num\u00e9ro de t\u00e9l\u00e9phone\" data-name=\"numeric-field_3\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_4_dropdown_1' aria-label=\"Niveau de plong\u00e9e\">Niveau de plong\u00e9e<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_1\" id=\"ff_5_4_dropdown_1\" class=\"ff-el-form-control\" data-name=\"dropdown_1\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\">Pour s\u00e9lectionner<\/option><option value=\"Je n&#039;ai jamais plong\u00e9\"  >Je n&#8217;ai jamais plong\u00e9<\/option><option value=\"D\u00e9butant\"  >D\u00e9butant<\/option><option value=\"Interm\u00e9diaire\"  >Interm\u00e9diaire<\/option><option value=\"Avanc\u00e9\"  >Avanc\u00e9<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_4_country-list' aria-label=\"Pays\">Pays<\/label><\/div><div class='ff-el-input--content'><select name=\"country-list\" id=\"ff_5_4_country-list\" class=\"ff-el-form-control\" placeholder=\"Choisissez le pays\" data-name=\"country-list\" aria-invalid='false' aria-required=true><option value=''>Choisissez le pays<\/option><option value='AF' >Afghanistan<\/option><option value='AX' >Aland Islands<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctica<\/option><option value='AG' >Antigua and Barbuda<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BY' >Belarus<\/option><option value='PW' >Belau<\/option><option value='BE' >Belgium<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Saint Eustatius and Saba<\/option><option value='BA' >Bosnia and Herzegovina<\/option><option value='BW' >Botswana<\/option><option value='BV' >Bouvet Island<\/option><option value='BR' >Brazil<\/option><option value='IO' >British Indian Ocean Territory<\/option><option value='VG' >British Virgin Islands<\/option><option value='BN' >Brunei<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='KH' >Cambodia<\/option><option value='CM' >Cameroon<\/option><option value='CA' >Canada<\/option><option value='CV' >Cape Verde<\/option><option value='KY' >Cayman Islands<\/option><option value='CF' >Central African Republic<\/option><option value='TD' >Chad<\/option><option value='CL' >Chile<\/option><option value='CN' >China<\/option><option value='CX' >Christmas Island<\/option><option value='CC' >Cocos (Keeling) Islands<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comoros<\/option><option value='CK' >Cook Islands<\/option><option value='CR' >Costa Rica<\/option><option value='HR' >Croatia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura&ccedil;ao<\/option><option value='CY' >Cyprus<\/option><option value='CZ' >Czech Republic<\/option><option value='CD' >Democratic Republic of the Congo (Kinshasa)<\/option><option value='DK' >Denmark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominica<\/option><option value='DO' >Dominican Republic<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egypt<\/option><option value='SV' >El Salvador<\/option><option value='GQ' >Equatorial Guinea<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='ET' >Ethiopia<\/option><option value='FK' >Falkland Islands<\/option><option value='FO' >Faroe Islands<\/option><option value='FJ' >Fiji<\/option><option value='FI' >Finland<\/option><option value='FR' >France<\/option><option value='GF' >French Guiana<\/option><option value='PF' >French Polynesia<\/option><option value='TF' >French Southern Territories<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germany<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GR' >Greece<\/option><option value='GL' >Greenland<\/option><option value='GD' >Grenada<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GN' >Guinea<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HM' >Heard Island and McDonald Islands<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hungary<\/option><option value='IS' >Iceland<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Ireland<\/option><option value='IM' >Isle of Man<\/option><option value='IL' >Israel<\/option><option value='IT' >Italy<\/option><option value='CI' >Ivory Coast<\/option><option value='JM' >Jamaica<\/option><option value='JP' >Japan<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordan<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='XK' >Kosovo<\/option><option value='KW' >Kuwait<\/option><option value='KG' >Kyrgyzstan<\/option><option value='LA' >Laos<\/option><option value='LV' >Latvia<\/option><option value='LB' >Lebanon<\/option><option value='LS' >Lesotho<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libya<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lithuania<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao S.A.R., China<\/option><option value='MK' >Macedonia<\/option><option value='MG' >Madagascar<\/option><option value='MW' >Malawi<\/option><option value='MY' >Malaysia<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MH' >Marshall Islands<\/option><option value='MQ' >Martinique<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldova<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MA' >Morocco<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NL' >Netherlands<\/option><option value='NC' >New Caledonia<\/option><option value='NZ' >New Zealand<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NF' >Norfolk Island<\/option><option value='KP' >North Korea<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norway<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PS' >Palestinian Territory<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua New Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Poland<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='QA' >Qatar<\/option><option value='CG' >Republic of the Congo (Brazzaville)<\/option><option value='RE' >Reunion<\/option><option value='RO' >Romania<\/option><option value='RU' >Russia<\/option><option value='RW' >Rwanda<\/option><option value='BL' >Saint Barth&eacute;lemy<\/option><option value='SH' >Saint Helena<\/option><option value='KN' >Saint Kitts and Nevis<\/option><option value='LC' >Saint Lucia<\/option><option value='SX' >Saint Martin (Dutch part)<\/option><option value='MF' >Saint Martin (French part)<\/option><option value='PM' >Saint Pierre and Miquelon<\/option><option value='VC' >Saint Vincent and the Grenadines<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tome and Principe<\/option><option value='SA' >Saudi Arabia<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SK' >Slovakia<\/option><option value='SI' >Slovenia<\/option><option value='SB' >Solomon Islands<\/option><option value='SO' >Somalia<\/option><option value='ZA' >South Africa<\/option><option value='GS' >South Georgia\/Sandwich Islands<\/option><option value='KR' >South Korea<\/option><option value='SS' >South Sudan<\/option><option value='ES' >Spain<\/option><option value='LK' >Sri Lanka<\/option><option value='SD' >Sudan<\/option><option value='SR' >Suriname<\/option><option value='SJ' >Svalbard and Jan Mayen<\/option><option value='SZ' >Swaziland<\/option><option value='SE' >Sweden<\/option><option value='CH' >Switzerland<\/option><option value='SY' >Syria<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzania<\/option><option value='TH' >Thailand<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad and Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >Turkey<\/option><option value='TM' >Turkmenistan<\/option><option value='TC' >Turks and Caicos Islands<\/option><option value='TV' >Tuvalu<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='AE' >United Arab Emirates<\/option><option value='GB' >United Kingdom (UK)<\/option><option value='US' >United States (US)<\/option><option value='UM' >United States (US) Minor Outlying Islands<\/option><option value='VI' >United States (US) Virgin Islands<\/option><option value='UY' >Uruguay<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VA' >Vatican<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='WF' >Wallis and Futuna<\/option><option value='EH' >Western Sahara<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><\/select><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-5_1\" ><p style=\"text-align: left\" align=\"center\"><strong>ANNEXE I<\/strong><\/p>\n<p style=\"text-align: left\" align=\"center\"><strong>Questionnaire sur l&#8217;\u00e9tat de sant\u00e9 de la plong\u00e9e r\u00e9cr\u00e9ative<\/strong><\/p>\n<p style=\"text-align: left\" align=\"center\">La plong\u00e9e n\u00e9cessite une bonne sant\u00e9 physique et mentale. Certaines conditions m\u00e9dicales peuvent \u00eatre dangereuses pendant la plong\u00e9e, \u00e9num\u00e9r\u00e9es ci-dessous. Ceux qui ont ou sont pr\u00e9dispos\u00e9s \u00e0 l&#8217;une de ces conditions doivent \u00eatre \u00e9valu\u00e9s par un m\u00e9decin. Ce questionnaire m\u00e9dical du plongeur fournit une base pour d\u00e9terminer si vous devez demander une telle \u00e9valuation. Si vous avez des inqui\u00e9tudes concernant votre aptitude \u00e0 plonger et qu&#8217;elles ne sont pas repr\u00e9sent\u00e9es sur ce formulaire, veuillez consulter votre m\u00e9decin avant de plonger. Les r\u00e9f\u00e9rences \u00e0 la \u00ab\u00a0plong\u00e9e\u00a0\u00bb sous cette forme incluent \u00e0 la fois la plong\u00e9e sous-marine r\u00e9cr\u00e9ative et la plong\u00e9e en apn\u00e9e. Ce formulaire est con\u00e7u principalement comme un examen m\u00e9dical initial pour les nouveaux plongeurs, mais convient \u00e9galement aux plongeurs en formation continue. Pour votre s\u00e9curit\u00e9 et celle des autres personnes susceptibles de plonger avec vous, r\u00e9pondez honn\u00eatement \u00e0 toutes les questions.<\/p>\n<p style=\"text-align: left\" align=\"center\"><strong>INSTRUCTIONS<\/strong><\/p>\n<p style=\"text-align: left\" align=\"center\">Remplissez ce questionnaire comme pr\u00e9requis pour la formation \u00e0 l&#8217;apn\u00e9e ou \u00e0 la plong\u00e9e sous-marine.<br \/>Remarque aux femmes\u00a0: si vous \u00eates enceinte ou essayez de le devenir, <strong>ne plongez pas.<\/strong><\/p><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Certificat m\u00e9dical\">Certificat m\u00e9dical<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_8e592c85b3f980efea4b64f2807fd6b3><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui, j&#039;ai un certificat\"  id='checkbox_8e592c85b3f980efea4b64f2807fd6b3' aria-label='Oui, j&#039;ai un certificat' aria-invalid='false' aria-required=true> <span>Oui, j&#8217;ai un certificat<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_d7af956d10ea84be0671eb802b2971a6><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Non, je n&#039;ai pas de certificat\"  id='checkbox_d7af956d10ea84be0671eb802b2971a6' aria-label='Non, je n&#039;ai pas de certificat' aria-invalid='false' aria-required=true> <span>Non, je n&#8217;ai pas de certificat<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"1. J&#039;ai eu des probl\u00e8mes pulmonaires ou respiratoires, cardiaques ou sanguins.\">1. J&#8217;ai eu des probl\u00e8mes pulmonaires ou respiratoires, cardiaques ou sanguins.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_40_308ee2022821eb234605c9abc88200e4><input  type=\"checkbox\" name=\"checkbox_40[]\" data-name=\"checkbox_40\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_40_308ee2022821eb234605c9abc88200e4' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_40_0dac6e7deaf67c66bf1985a2559051ca><input  type=\"checkbox\" name=\"checkbox_40[]\" data-name=\"checkbox_40\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_40_0dac6e7deaf67c66bf1985a2559051ca' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai ou j&#039;ai eu : Chirurgie thoracique, chirurgie cardiaque, chirurgie valvulaire cardiaque, mise en place d&#039;un stent ou pneumothorax (poumon effondr\u00e9).\">J&#8217;ai ou j&#8217;ai eu : Chirurgie thoracique, chirurgie cardiaque, chirurgie valvulaire cardiaque, mise en place d&#8217;un stent ou pneumothorax (poumon effondr\u00e9).<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_3_dd4eded814a6af7bd5b2047374c2da88><input  type=\"checkbox\" name=\"checkbox_3[]\" data-name=\"checkbox_3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_3_dd4eded814a6af7bd5b2047374c2da88' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_3_6910ea60fed87b9043b42d3d744a3f05><input  type=\"checkbox\" name=\"checkbox_3[]\" data-name=\"checkbox_3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_3_6910ea60fed87b9043b42d3d744a3f05' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai ou j&#039;ai eu : De l&#039;asthme, une respiration sifflante, des allergies graves, du rhume des foins ou des voies respiratoires congestionn\u00e9es au cours des 12 derniers mois, ce qui limite mon activit\u00e9 physique ou mon exercice.\">J&#8217;ai ou j&#8217;ai eu : De l&#8217;asthme, une respiration sifflante, des allergies graves, du rhume des foins ou des voies respiratoires congestionn\u00e9es au cours des 12 derniers mois, ce qui limite mon activit\u00e9 physique ou mon exercice.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_4_e34fb9b5c311c276a257e1797dbb0a85><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_4_e34fb9b5c311c276a257e1797dbb0a85' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_4_9da244c2175e7d1ae8d49268732aae1a><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_4_9da244c2175e7d1ae8d49268732aae1a' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai ou j&#039;ai eu : Un probl\u00e8me ou une maladie cardiaque telle que : angine de poitrine, douleur thoracique \u00e0 l&#039;effort, insuffisance cardiaque, \u0153d\u00e8me pulmonaire, cardiomyopathie ou accident vasculaire c\u00e9r\u00e9bral, ou je prends des m\u00e9dicaments pour toute affection cardiaque.\">J&#8217;ai ou j&#8217;ai eu : Un probl\u00e8me ou une maladie cardiaque telle que : angine de poitrine, douleur thoracique \u00e0 l&#8217;effort, insuffisance cardiaque, \u0153d\u00e8me pulmonaire, cardiomyopathie ou accident vasculaire c\u00e9r\u00e9bral, ou je prends des m\u00e9dicaments pour toute affection cardiaque.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_5_dd8606b1e6f73c6774783a0be927ad28><input  type=\"checkbox\" name=\"checkbox_5[]\" data-name=\"checkbox_5\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_5_dd8606b1e6f73c6774783a0be927ad28' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_5_f87f82f19bdfa8f214b3175ce09dd5a9><input  type=\"checkbox\" name=\"checkbox_5[]\" data-name=\"checkbox_5\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_5_f87f82f19bdfa8f214b3175ce09dd5a9' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai ou j&#039;ai eu : Une bronchite r\u00e9currente et une toux persistante au cours des 12 derniers mois, ou j&#039;ai re\u00e7u un diagnostic d&#039;emphys\u00e8me.\">J&#8217;ai ou j&#8217;ai eu : Une bronchite r\u00e9currente et une toux persistante au cours des 12 derniers mois, ou j&#8217;ai re\u00e7u un diagnostic d&#8217;emphys\u00e8me.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_6_259cedb00c99dc40e779a027f8a1fc14><input  type=\"checkbox\" name=\"checkbox_6[]\" data-name=\"checkbox_6\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_6_259cedb00c99dc40e779a027f8a1fc14' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_6_ac20c03c84b3e6842cc486f4057fe92e><input  type=\"checkbox\" name=\"checkbox_6[]\" data-name=\"checkbox_6\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_6_ac20c03c84b3e6842cc486f4057fe92e' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"2. J&#039;ai plus de 45 ans\">2. J&#8217;ai plus de 45 ans<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_1_9cc058aa79c8e8edbeea50e649f6129b><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_1_9cc058aa79c8e8edbeea50e649f6129b' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_1_48bff3a27bfd93776c388176a4b5b174><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_1_48bff3a27bfd93776c388176a4b5b174' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai plus de 45 ans et : Je fume ou inhale actuellement de la nicotine par d&#039;autres moyens\">J&#8217;ai plus de 45 ans et : Je fume ou inhale actuellement de la nicotine par d&#8217;autres moyens<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_7_c7e50846069f83025fe7204f335783d4><input  type=\"checkbox\" name=\"checkbox_7[]\" data-name=\"checkbox_7\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_7_c7e50846069f83025fe7204f335783d4' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_7_8c51d7c0156d6f0a85811841ceb401d4><input  type=\"checkbox\" name=\"checkbox_7[]\" data-name=\"checkbox_7\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_7_8c51d7c0156d6f0a85811841ceb401d4' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai plus de 45 ans et : J&#039;ai un taux de cholest\u00e9rol \u00e9lev\u00e9.\">J&#8217;ai plus de 45 ans et : J&#8217;ai un taux de cholest\u00e9rol \u00e9lev\u00e9.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_8_eb6911f957294aab6d9f1a4d030a6149><input  type=\"checkbox\" name=\"checkbox_8[]\" data-name=\"checkbox_8\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_8_eb6911f957294aab6d9f1a4d030a6149' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_8_0919cd5158781b9a4b14c73ff40dbfea><input  type=\"checkbox\" name=\"checkbox_8[]\" data-name=\"checkbox_8\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_8_0919cd5158781b9a4b14c73ff40dbfea' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai plus de 45 ans et : J&#039;ai une pression art\u00e9rielle \u00e9lev\u00e9e\">J&#8217;ai plus de 45 ans et : J&#8217;ai une pression art\u00e9rielle \u00e9lev\u00e9e<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_10_7fb37c525c4846e800fe41a5838367d9><input  type=\"checkbox\" name=\"checkbox_10[]\" data-name=\"checkbox_10\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_10_7fb37c525c4846e800fe41a5838367d9' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_10_dcbc085d359e7a4cfac65786b4ac2f21><input  type=\"checkbox\" name=\"checkbox_10[]\" data-name=\"checkbox_10\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_10_dcbc085d359e7a4cfac65786b4ac2f21' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai plus de 45 ans et : j&#039;ai eu un parent (consanguinit\u00e9 1er ou 2\u00e8me degr\u00e9) d\u00e9c\u00e9d\u00e9 de mort subite ou d&#039;une maladie cardiaque ou d&#039;un accident vasculaire c\u00e9r\u00e9bral avant l&#039;\u00e2ge de 50 ans, ou j&#039;ai des ant\u00e9c\u00e9dents familiaux de maladie cardiaque avant l&#039;\u00e2ge de 50 ans (y compris des rythmes cardiaques anormaux, une maladie coronarienne ou une cardiomyopathie)\">J&#8217;ai plus de 45 ans et : j&#8217;ai eu un parent (consanguinit\u00e9 1er ou 2\u00e8me degr\u00e9) d\u00e9c\u00e9d\u00e9 de mort subite ou d&#8217;une maladie cardiaque ou d&#8217;un accident vasculaire c\u00e9r\u00e9bral avant l&#8217;\u00e2ge de 50 ans, ou j&#8217;ai des ant\u00e9c\u00e9dents familiaux de maladie cardiaque avant l&#8217;\u00e2ge de 50 ans (y compris des rythmes cardiaques anormaux, une maladie coronarienne ou une cardiomyopathie)<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_9_a4c0dc5e094ac61201c27147ac2b446d><input  type=\"checkbox\" name=\"checkbox_9[]\" data-name=\"checkbox_9\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_9_a4c0dc5e094ac61201c27147ac2b446d' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_9_8a3e2b4b5cb9acf5119bc1d01feaf8c8><input  type=\"checkbox\" name=\"checkbox_9[]\" data-name=\"checkbox_9\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_9_8a3e2b4b5cb9acf5119bc1d01feaf8c8' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"3. Il m&#039;est difficile de faire de l&#039;exercice mod\u00e9r\u00e9 (par exemple, marcher 1,6 kilom\u00e8tre en 12 minutes ou nager 200 m\u00e8tres sans repos), ou je n&#039;ai pas pu participer \u00e0 une activit\u00e9 physique normale pour des raisons de forme physique ou de sant\u00e9 dans le 12 derniers mois.\">3. Il m&#8217;est difficile de faire de l&#8217;exercice mod\u00e9r\u00e9 (par exemple, marcher 1,6 kilom\u00e8tre en 12 minutes ou nager 200 m\u00e8tres sans repos), ou je n&#8217;ai pas pu participer \u00e0 une activit\u00e9 physique normale pour des raisons de forme physique ou de sant\u00e9 dans le 12 derniers mois.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_2_2bc723e3ede9cb04f780dd15249aa71f><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_2_2bc723e3ede9cb04f780dd15249aa71f' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_2_bf4ba1767380249c47b492bc77ae0257><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_2_bf4ba1767380249c47b492bc77ae0257' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"4. J&#039;ai eu des probl\u00e8mes avec mes yeux, mes oreilles et mes voies nasales ou mes sinus.\">4. J&#8217;ai eu des probl\u00e8mes avec mes yeux, mes oreilles et mes voies nasales ou mes sinus.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_12_39127639f1bac14c7f009982db449416><input  type=\"checkbox\" name=\"checkbox_12[]\" data-name=\"checkbox_12\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_12_39127639f1bac14c7f009982db449416' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_12_5abdb7c5ea518bd89c9d518474bb7f0e><input  type=\"checkbox\" name=\"checkbox_12[]\" data-name=\"checkbox_12\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_12_5abdb7c5ea518bd89c9d518474bb7f0e' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai ou j&#039;ai eu : Chirurgie des sinus au cours des 6 derniers mois.\">J&#8217;ai ou j&#8217;ai eu : Chirurgie des sinus au cours des 6 derniers mois.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_13_8e8abd61fcd7eb44b8fdaabbd0b90db5><input  type=\"checkbox\" name=\"checkbox_13[]\" data-name=\"checkbox_13\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_13_8e8abd61fcd7eb44b8fdaabbd0b90db5' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_13_ef9c7e87c5873de78b68ab1974f9d559><input  type=\"checkbox\" name=\"checkbox_13[]\" data-name=\"checkbox_13\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_13_ef9c7e87c5873de78b68ab1974f9d559' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai ou j&#039;ai eu : des maladies de l&#039;oreille ou une chirurgie de l&#039;oreille, une perte auditive ou des troubles de l&#039;\u00e9quilibre.\">J&#8217;ai ou j&#8217;ai eu : des maladies de l&#8217;oreille ou une chirurgie de l&#8217;oreille, une perte auditive ou des troubles de l&#8217;\u00e9quilibre.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_11_9923c8361d1e9d78fe6fe3007c2b8d7f><input  type=\"checkbox\" name=\"checkbox_11[]\" data-name=\"checkbox_11\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_11_9923c8361d1e9d78fe6fe3007c2b8d7f' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_11_079df0ca39f15a9f1078fbab16e22232><input  type=\"checkbox\" name=\"checkbox_11[]\" data-name=\"checkbox_11\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_11_079df0ca39f15a9f1078fbab16e22232' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai ou j&#039;ai eu : Sinusite r\u00e9currente au cours des 12 derniers mois.\">J&#8217;ai ou j&#8217;ai eu : Sinusite r\u00e9currente au cours des 12 derniers mois.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_14_001900909bd828eb4766fa5f6590b6c8><input  type=\"checkbox\" name=\"checkbox_14[]\" data-name=\"checkbox_14\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_14_001900909bd828eb4766fa5f6590b6c8' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_14_9619a0f3d9e402d18b53323881dff0a7><input  type=\"checkbox\" name=\"checkbox_14[]\" data-name=\"checkbox_14\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_14_9619a0f3d9e402d18b53323881dff0a7' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai ou j&#039;ai eu : Chirurgie occulte au cours des 3 derniers mois.\">J&#8217;ai ou j&#8217;ai eu : Chirurgie occulte au cours des 3 derniers mois.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_18_cb6a8b8a98e39ca0f2a5068d23f4aa8f><input  type=\"checkbox\" name=\"checkbox_18[]\" data-name=\"checkbox_18\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_18_cb6a8b8a98e39ca0f2a5068d23f4aa8f' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_18_63e43160ef46d406d156cdc49dcf5e17><input  type=\"checkbox\" name=\"checkbox_18[]\" data-name=\"checkbox_18\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_18_63e43160ef46d406d156cdc49dcf5e17' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"5. J&#039;ai subi une intervention chirurgicale au cours des 12 derniers mois ou j&#039;ai des probl\u00e8mes persistants li\u00e9 \u00e0 une intervention chirurgicale ant\u00e9rieure.\">5. J&#8217;ai subi une intervention chirurgicale au cours des 12 derniers mois ou j&#8217;ai des probl\u00e8mes persistants li\u00e9 \u00e0 une intervention chirurgicale ant\u00e9rieure.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_16_3d79556b3c95c8c8cfdd2f66fa65875c><input  type=\"checkbox\" name=\"checkbox_16[]\" data-name=\"checkbox_16\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_16_3d79556b3c95c8c8cfdd2f66fa65875c' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_16_481c928c4abb46cac646aed78be891cb><input  type=\"checkbox\" name=\"checkbox_16[]\" data-name=\"checkbox_16\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_16_481c928c4abb46cac646aed78be891cb' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"6. J&#039;ai perdu connaissance, j&#039;ai eu des migraines, des convulsions, un accident vasculaire c\u00e9r\u00e9bral, un traumatisme cr\u00e2nien important ou une blessure ou une maladie neurologique subie.\">6. J&#8217;ai perdu connaissance, j&#8217;ai eu des migraines, des convulsions, un accident vasculaire c\u00e9r\u00e9bral, un traumatisme cr\u00e2nien important ou une blessure ou une maladie neurologique subie.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_17_b48b63c1ff95127d15774b6d228c3979><input  type=\"checkbox\" name=\"checkbox_17[]\" data-name=\"checkbox_17\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_17_b48b63c1ff95127d15774b6d228c3979' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_17_fb0e87e61a9d8a806a9bda1755cc0ca3><input  type=\"checkbox\" name=\"checkbox_17[]\" data-name=\"checkbox_17\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_17_fb0e87e61a9d8a806a9bda1755cc0ca3' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai ou j&#039;ai eu : Traumatisme cr\u00e2nien avec perte de connaissance au cours des 5 derni\u00e8res ann\u00e9es.\">J&#8217;ai ou j&#8217;ai eu : Traumatisme cr\u00e2nien avec perte de connaissance au cours des 5 derni\u00e8res ann\u00e9es.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_15_40e22d489f59f9f190a22683241e8d33><input  type=\"checkbox\" name=\"checkbox_15[]\" data-name=\"checkbox_15\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_15_40e22d489f59f9f190a22683241e8d33' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_15_d0f0c6e4a34855586719323f273e5bf7><input  type=\"checkbox\" name=\"checkbox_15[]\" data-name=\"checkbox_15\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_15_d0f0c6e4a34855586719323f273e5bf7' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai ou j&#039;ai eu : Blessures ou maladies neurologiques persistantes.\">J&#8217;ai ou j&#8217;ai eu : Blessures ou maladies neurologiques persistantes.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_19_c442afb799360cac9a7e0edae8ca80d2><input  type=\"checkbox\" name=\"checkbox_19[]\" data-name=\"checkbox_19\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_19_c442afb799360cac9a7e0edae8ca80d2' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_19_1c4efc6943d1f668c36bab833bd90bf8><input  type=\"checkbox\" name=\"checkbox_19[]\" data-name=\"checkbox_19\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_19_1c4efc6943d1f668c36bab833bd90bf8' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai ou j&#039;ai eu : Des migraines r\u00e9currentes au cours des 12 derniers mois, ou je prends des m\u00e9dicaments pour les pr\u00e9venir.\">J&#8217;ai ou j&#8217;ai eu : Des migraines r\u00e9currentes au cours des 12 derniers mois, ou je prends des m\u00e9dicaments pour les pr\u00e9venir.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_20_60bbe480b0f175815399a272d742ccec><input  type=\"checkbox\" name=\"checkbox_20[]\" data-name=\"checkbox_20\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_20_60bbe480b0f175815399a272d742ccec' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_20_cb296a557b4cc1f5ecfc6a0f05776cdf><input  type=\"checkbox\" name=\"checkbox_20[]\" data-name=\"checkbox_20\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_20_cb296a557b4cc1f5ecfc6a0f05776cdf' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai ou j&#039;ai eu : \u00c9pilepsie, crises ou convulsions, ou je prends des m\u00e9dicaments pour les pr\u00e9venir.\">J&#8217;ai ou j&#8217;ai eu : \u00c9pilepsie, crises ou convulsions, ou je prends des m\u00e9dicaments pour les pr\u00e9venir.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_21_f6faad9d90dd6fec2652ada40e2cb698><input  type=\"checkbox\" name=\"checkbox_21[]\" data-name=\"checkbox_21\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_21_f6faad9d90dd6fec2652ada40e2cb698' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_21_786731627ddbe1ed6e0613e2347bde41><input  type=\"checkbox\" name=\"checkbox_21[]\" data-name=\"checkbox_21\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_21_786731627ddbe1ed6e0613e2347bde41' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"7. J&#039;ai eu des probl\u00e8mes psychologiques, on m&#039;a diagnostiqu\u00e9 un trouble d&#039;apprentissage, un trouble de la personnalit\u00e9, des attaques de panique ou une d\u00e9pendance aux drogues ou \u00e0 l&#039;alcool.\">7. J&#8217;ai eu des probl\u00e8mes psychologiques, on m&#8217;a diagnostiqu\u00e9 un trouble d&#8217;apprentissage, un trouble de la personnalit\u00e9, des attaques de panique ou une d\u00e9pendance aux drogues ou \u00e0 l&#8217;alcool.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_27_986a4b9b105de12c57e53869766d46b2><input  type=\"checkbox\" name=\"checkbox_27[]\" data-name=\"checkbox_27\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_27_986a4b9b105de12c57e53869766d46b2' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_27_97c3d7b532be1defc92f4741ddd90480><input  type=\"checkbox\" name=\"checkbox_27[]\" data-name=\"checkbox_27\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_27_97c3d7b532be1defc92f4741ddd90480' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai ou j&#039;ai eu : Des probl\u00e8mes de sant\u00e9 comportementale, mentaux ou psychologiques qui n\u00e9cessitent un traitement m\u00e9dical ou psychiatrique.\">J&#8217;ai ou j&#8217;ai eu : Des probl\u00e8mes de sant\u00e9 comportementale, mentaux ou psychologiques qui n\u00e9cessitent un traitement m\u00e9dical ou psychiatrique.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_23_d16c78757954249e5faafec5bc434b94><input  type=\"checkbox\" name=\"checkbox_23[]\" data-name=\"checkbox_23\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_23_d16c78757954249e5faafec5bc434b94' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_23_578d6e95ac22b2fd3a7f2a4163da9982><input  type=\"checkbox\" name=\"checkbox_23[]\" data-name=\"checkbox_23\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_23_578d6e95ac22b2fd3a7f2a4163da9982' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai ou j&#039;ai eu : une d\u00e9pression majeure, une tendance suicidaire, des attaques de panique, un trouble bipolaire incontr\u00f4l\u00e9 qui n\u00e9cessite des m\u00e9dicaments\/un traitement psychiatrique.\">J&#8217;ai ou j&#8217;ai eu : une d\u00e9pression majeure, une tendance suicidaire, des attaques de panique, un trouble bipolaire incontr\u00f4l\u00e9 qui n\u00e9cessite des m\u00e9dicaments\/un traitement psychiatrique.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_24_3763259b16f3be5223d71b73cd5592fe><input  type=\"checkbox\" name=\"checkbox_24[]\" data-name=\"checkbox_24\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_24_3763259b16f3be5223d71b73cd5592fe' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_24_dbb8559632e5c6456471ef34bfc75aaa><input  type=\"checkbox\" name=\"checkbox_24[]\" data-name=\"checkbox_24\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_24_dbb8559632e5c6456471ef34bfc75aaa' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai ou j&#039;ai eu : On m&#039;a diagnostiqu\u00e9 un probl\u00e8me de sant\u00e9 mentale ou un trouble d&#039;apprentissage ou de d\u00e9veloppement qui n\u00e9cessite des soins continus.\">J&#8217;ai ou j&#8217;ai eu : On m&#8217;a diagnostiqu\u00e9 un probl\u00e8me de sant\u00e9 mentale ou un trouble d&#8217;apprentissage ou de d\u00e9veloppement qui n\u00e9cessite des soins continus.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_25_b3687647b4d6b6fa987f34281feadec2><input  type=\"checkbox\" name=\"checkbox_25[]\" data-name=\"checkbox_25\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_25_b3687647b4d6b6fa987f34281feadec2' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_25_7be89f0a907452940b5e064ba32639ba><input  type=\"checkbox\" name=\"checkbox_25[]\" data-name=\"checkbox_25\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_25_7be89f0a907452940b5e064ba32639ba' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai ou j&#039;ai eu : Une d\u00e9pendance \u00e0 la drogue ou \u00e0 l&#039;alcool n\u00e9cessitant un traitement au cours des 5 derni\u00e8res ann\u00e9es.\">J&#8217;ai ou j&#8217;ai eu : Une d\u00e9pendance \u00e0 la drogue ou \u00e0 l&#8217;alcool n\u00e9cessitant un traitement au cours des 5 derni\u00e8res ann\u00e9es.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_28_77c97812e07629762297b000cb1a55f6><input  type=\"checkbox\" name=\"checkbox_28[]\" data-name=\"checkbox_28\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_28_77c97812e07629762297b000cb1a55f6' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_28_3b797c221af57cbe7b39b6d0208472e3><input  type=\"checkbox\" name=\"checkbox_28[]\" data-name=\"checkbox_28\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_28_3b797c221af57cbe7b39b6d0208472e3' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"8. J&#039;ai eu des probl\u00e8mes de dos, une hernie, des ulc\u00e8res ou du diab\u00e8te.\">8. J&#8217;ai eu des probl\u00e8mes de dos, une hernie, des ulc\u00e8res ou du diab\u00e8te.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_22_509eb17e7463652e51754d9409a2c352><input  type=\"checkbox\" name=\"checkbox_22[]\" data-name=\"checkbox_22\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_22_509eb17e7463652e51754d9409a2c352' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_22_db5e7a077ad61a49d57e47d947850802><input  type=\"checkbox\" name=\"checkbox_22[]\" data-name=\"checkbox_22\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_22_db5e7a077ad61a49d57e47d947850802' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai ou j&#039;ai eu : Des probl\u00e8mes de dos r\u00e9currents au cours des 6 derniers mois qui limitent mon activit\u00e9 quotidienne.\">J&#8217;ai ou j&#8217;ai eu : Des probl\u00e8mes de dos r\u00e9currents au cours des 6 derniers mois qui limitent mon activit\u00e9 quotidienne.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_26_495b6b0f756a57cff7ee38417784b4e7><input  type=\"checkbox\" name=\"checkbox_26[]\" data-name=\"checkbox_26\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_26_495b6b0f756a57cff7ee38417784b4e7' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_26_81ce69d7407178f9267c1d31120ebe9c><input  type=\"checkbox\" name=\"checkbox_26[]\" data-name=\"checkbox_26\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_26_81ce69d7407178f9267c1d31120ebe9c' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai ou j&#039;ai eu : Chirurgie du dos ou de la colonne vert\u00e9brale au cours des 12 derniers mois.\">J&#8217;ai ou j&#8217;ai eu : Chirurgie du dos ou de la colonne vert\u00e9brale au cours des 12 derniers mois.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_29_eea7b9e41a9182e0fc937a5cf9ea7818><input  type=\"checkbox\" name=\"checkbox_29[]\" data-name=\"checkbox_29\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_29_eea7b9e41a9182e0fc937a5cf9ea7818' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_29_f0a28d73f575b0c0df0b1c438789a410><input  type=\"checkbox\" name=\"checkbox_29[]\" data-name=\"checkbox_29\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_29_f0a28d73f575b0c0df0b1c438789a410' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai ou j&#039;ai eu : Diab\u00e8te, contr\u00f4l\u00e9 par l&#039;insuline ou l&#039;alimentation, ou diab\u00e8te gestationnel au cours des 12 derniers mois.\">J&#8217;ai ou j&#8217;ai eu : Diab\u00e8te, contr\u00f4l\u00e9 par l&#8217;insuline ou l&#8217;alimentation, ou diab\u00e8te gestationnel au cours des 12 derniers mois.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_30_3a496bac0e569edb98348c2a69c2c480><input  type=\"checkbox\" name=\"checkbox_30[]\" data-name=\"checkbox_30\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_30_3a496bac0e569edb98348c2a69c2c480' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_30_b11fb71cbcf9d0455a6a27e16912f371><input  type=\"checkbox\" name=\"checkbox_30[]\" data-name=\"checkbox_30\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_30_b11fb71cbcf9d0455a6a27e16912f371' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai ou j&#039;ai eu : Une hernie non corrig\u00e9e qui limite mes capacit\u00e9s physiques.\">J&#8217;ai ou j&#8217;ai eu : Une hernie non corrig\u00e9e qui limite mes capacit\u00e9s physiques.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_31_cb1bbdac4e25394e437b3c16644a137c><input  type=\"checkbox\" name=\"checkbox_31[]\" data-name=\"checkbox_31\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_31_cb1bbdac4e25394e437b3c16644a137c' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_31_32dd947cd3265f42f34ac2f580888741><input  type=\"checkbox\" name=\"checkbox_31[]\" data-name=\"checkbox_31\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_31_32dd947cd3265f42f34ac2f580888741' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai ou j&#039;ai eu : des ulc\u00e8res actifs ou non trait\u00e9s, des plaies probl\u00e9matiques ou une chirurgie d&#039;un ulc\u00e8re au cours des 6 derniers mois.\">J&#8217;ai ou j&#8217;ai eu : des ulc\u00e8res actifs ou non trait\u00e9s, des plaies probl\u00e9matiques ou une chirurgie d&#8217;un ulc\u00e8re au cours des 6 derniers mois.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_32_2240e5b69cbe829a2a38e24128965073><input  type=\"checkbox\" name=\"checkbox_32[]\" data-name=\"checkbox_32\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_32_2240e5b69cbe829a2a38e24128965073' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_32_e1c510f8a70bcdaba83aa280b730bfd4><input  type=\"checkbox\" name=\"checkbox_32[]\" data-name=\"checkbox_32\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_32_e1c510f8a70bcdaba83aa280b730bfd4' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"9. J&#039;ai eu des probl\u00e8mes gastriques ou intestinaux, y compris une diarrh\u00e9e r\u00e9cente.\">9. J&#8217;ai eu des probl\u00e8mes gastriques ou intestinaux, y compris une diarrh\u00e9e r\u00e9cente.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_33_ad2bb04dd447ba0fbeb4bda577a5519c><input  type=\"checkbox\" name=\"checkbox_33[]\" data-name=\"checkbox_33\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_33_ad2bb04dd447ba0fbeb4bda577a5519c' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_33_985b7901ed0985c131fbd5ea5a784e00><input  type=\"checkbox\" name=\"checkbox_33[]\" data-name=\"checkbox_33\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_33_985b7901ed0985c131fbd5ea5a784e00' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai : une op\u00e9ration de stomie et je ne suis pas m\u00e9dicalement autoris\u00e9 \u00e0 nager ou \u00e0 pratiquer une activit\u00e9 physique.\">J&#8217;ai : une op\u00e9ration de stomie et je ne suis pas m\u00e9dicalement autoris\u00e9 \u00e0 nager ou \u00e0 pratiquer une activit\u00e9 physique.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_34_68dff425c61989069798be2e8a8bf7fa><input  type=\"checkbox\" name=\"checkbox_34[]\" data-name=\"checkbox_34\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_34_68dff425c61989069798be2e8a8bf7fa' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_34_3c9c515aa7ee584ac825186fbabe2536><input  type=\"checkbox\" name=\"checkbox_34[]\" data-name=\"checkbox_34\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_34_3c9c515aa7ee584ac825186fbabe2536' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai : D\u00e9shydratation n\u00e9cessitant une intervention m\u00e9dicale pour nager ou participer \u00e0 une activit\u00e9 physique.\">J&#8217;ai : D\u00e9shydratation n\u00e9cessitant une intervention m\u00e9dicale pour nager ou participer \u00e0 une activit\u00e9 physique.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_35_cb14b57fd5bc6cb00fa9f589338e6c90><input  type=\"checkbox\" name=\"checkbox_35[]\" data-name=\"checkbox_35\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_35_cb14b57fd5bc6cb00fa9f589338e6c90' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_35_97479397326e252ea8b9998b56f1e8e9><input  type=\"checkbox\" name=\"checkbox_35[]\" data-name=\"checkbox_35\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_35_97479397326e252ea8b9998b56f1e8e9' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai : Des ulc\u00e8res gastriques ou intestinaux actifs ou non trait\u00e9s ou une chirurgie de l&#039;ulc\u00e8re au cours des 6 derniers mois.\">J&#8217;ai : Des ulc\u00e8res gastriques ou intestinaux actifs ou non trait\u00e9s ou une chirurgie de l&#8217;ulc\u00e8re au cours des 6 derniers mois.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_36_39837278ff0ab5a91701d559459fcb7f><input  type=\"checkbox\" name=\"checkbox_36[]\" data-name=\"checkbox_36\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_36_39837278ff0ab5a91701d559459fcb7f' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_36_8b2fd64d5da3ae19674e3857d7b0f2ab><input  type=\"checkbox\" name=\"checkbox_36[]\" data-name=\"checkbox_36\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_36_8b2fd64d5da3ae19674e3857d7b0f2ab' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai : des br\u00fblures d&#039;estomac fr\u00e9quentes, des r\u00e9gurgitations ou un reflux gastro-oesophagien (RGO).\">J&#8217;ai : des br\u00fblures d&#8217;estomac fr\u00e9quentes, des r\u00e9gurgitations ou un reflux gastro-oesophagien (RGO).<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_37_b5839aad69285afa0915d6a00ebc7070><input  type=\"checkbox\" name=\"checkbox_37[]\" data-name=\"checkbox_37\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_37_b5839aad69285afa0915d6a00ebc7070' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_37_08e845821c19d0aa4efd73a1a8cf8941><input  type=\"checkbox\" name=\"checkbox_37[]\" data-name=\"checkbox_37\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_37_08e845821c19d0aa4efd73a1a8cf8941' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai : une colite ulc\u00e9reuse active ou non contr\u00f4l\u00e9e ou la maladie de Crohn.\">J&#8217;ai : une colite ulc\u00e9reuse active ou non contr\u00f4l\u00e9e ou la maladie de Crohn.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_38_e8e898bd3f66401cffea0238f19cccd5><input  type=\"checkbox\" name=\"checkbox_38[]\" data-name=\"checkbox_38\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oui\"  id='checkbox_38_e8e898bd3f66401cffea0238f19cccd5' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_38_53b066ae32b7d381f69a581dfa942554><input  type=\"checkbox\" name=\"checkbox_38[]\" data-name=\"checkbox_38\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Ne pas\"  id='checkbox_38_53b066ae32b7d381f69a581dfa942554' aria-label='Ne pas' aria-invalid='false' aria-required=true> <span>Ne pas<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"J&#039;ai : Chirurgie bariatrique au cours des 12 derniers mois.\">J&#8217;ai : Chirurgie bariatrique au cours des 12 derniers mois.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_39_af501dbdd3baec40463251b49fe00838><input  type=\"checkbox\" name=\"checkbox_39[]\" data-name=\"checkbox_39\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Si\"  id='checkbox_39_af501dbdd3baec40463251b49fe00838' aria-label='Si' aria-invalid='false' aria-required=true> <span>Si<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_39_74b198cbc59db16b3524c8e343b2f557><input  type=\"checkbox\" name=\"checkbox_39[]\" data-name=\"checkbox_39\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_39_74b198cbc59db16b3524c8e343b2f557' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-5_2\" ><p style=\"text-align: left\"><strong>Signature du participant<\/strong><\/p>\n<p style=\"text-align: left\">Si vous avez r\u00e9pondu NON aux 10 questions ci-dessus, une \u00e9valuation m\u00e9dicale n&#8217;est pas requise. Veuillez lire et accepter la d\u00e9claration du participant sign\u00e9e et dat\u00e9e ci-dessous.<br \/>D\u00e9claration du participant\u00a0: j&#8217;ai r\u00e9pondu honn\u00eatement \u00e0 toutes les questions et je comprends que j&#8217;accepte la responsabilit\u00e9 de toutes les cons\u00e9quences r\u00e9sultant de toute question que je pourrais avoir. r\u00e9pondre de mani\u00e8re inexacte ou ne pas divulguer tout probl\u00e8me de sant\u00e9 existant ou pass\u00e9.<br \/>Signature du participant (ou, si mineur, la signature du parent\/tuteur du participant est requise.)<\/p><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_1  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Singature\">Singature<\/label><\/div><div class='ff-el-input--content'><input type='text' name='signature' class='force-hide'>\n\n<div class=\"fluentform-signature-pad-wrapper\">\n    <canvas id='signature_5' \n            class='fluentform-signature-pad' \n            data-form-id='5'\n            data-pen-color='#333'\n            data-pen-size='2'\n            style='\n                background-color: #ffffff;\n                border: 2px dashed #FF2D00;\n                width: fit-content;\n            '\n            height=\"200\"\n    ><\/canvas>\n\n    <div class=\"ff-el-signature__actions\">\n        <div class='fluentform-signature-pad-actions'>\n            <button type='button' class='fluentform-signature-button fluentform-signature-clear'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 561 561\" xml:space=\"preserve\"><g><g id=\"loop\"><path d=\"M280.5,76.5V0l-102,102l102,102v-76.5c84.15,0,153,68.85,153,153c0,25.5-7.65,51-17.85,71.4l38.25,38.25C471.75,357,484.5,321.3,484.5,280.5C484.5,168.3,392.7,76.5,280.5,76.5z M280.5,433.5c-84.15,0-153-68.85-153-153c0-25.5,7.65-51,17.85-71.4l-38.25-38.25C89.25,204,76.5,239.7,76.5,280.5c0,112.2,91.8,204,204,204V561l102-102l-102-102V433.5z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n            \n            <button type='button' class='fluentform-signature-button fluentform-signature-undo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 497.25 497.25\" xml:space=\"preserve\"><g><g id=\"undo\"><path d=\"M248.625,89.25V0l-127.5,127.5l127.5,127.5V140.25c84.15,0,153,68.85,153,153c0,84.15-68.85,153-153,153c-84.15,0-153-68.85-153-153h-51c0,112.2,91.8,204,204,204s204-91.8,204-204S360.825,89.25,248.625,89.25z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n\n            <button type='button' class='fluentform-signature-button fluentform-signature-redo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 485.212 485.212\" xml:space=\"preserve\"><g><path d=\"M242.607,424.559c-75.252,0-136.468-61.209-136.468-136.465c0-75.252,61.216-136.466,136.468-136.466v90.978l151.629-121.302L242.607,0v90.978c-108.687,0-197.117,88.432-197.117,197.117c0,108.691,88.43,197.118,197.117,197.118c108.687,0,197.114-88.427,197.114-197.118h-60.645C379.077,363.35,317.859,424.559,242.607,424.559z\"\/><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n        <\/div>\n\n        <div class='ff-el-signature__actions-hint fluentform-signature-hint'>Signez ici<\/div>\n    <\/div>\n<\/div>\n<\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_5\"  class='ff-t-container ff-column-container ff_columns_total_3  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 34%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_5_4_datetime' aria-label=\"Date\">Date<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime\" id=\"ff_5_4_datetime\" class=\"ff-el-form-control ff-el-datepicker\" placeholder=\"Date\" data-name=\"datetime\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 34%;'><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 34%;'><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-5_3\" ><p style=\"text-align: left\"><strong>Si vous avez r\u00e9pondu OUI<\/strong> aux questions 3, 5 ou 10 ci-dessus ou \u00e0 l&#8217;une des questions de la page 2, veuillez lire et accepter la d\u00e9claration ci-dessus avec la date et signez-le, et apportez le <strong>formulaire d&#8217;\u00e9valuation du m\u00e9decin<\/strong> \u00e0 votre m\u00e9decin pour une \u00e9valuation m\u00e9dicale. La participation \u00e0 un programme de formation en plong\u00e9e n\u00e9cessite l&#8217;\u00e9valuation et l&#8217;approbation de votre m\u00e9decin.<\/p><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='Terms and Conditions: J&#039;ai lu et j&#039;accepte les Mentions l\u00e9gales et les Politique de confidentialit\u00e9 Contains 2 links. 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