{"id":918,"date":"2023-02-28T11:25:23","date_gmt":"2023-02-28T16:25:23","guid":{"rendered":"https:\/\/blossomhc.net\/?page_id=918"},"modified":"2023-02-28T11:25:23","modified_gmt":"2023-02-28T16:25:23","slug":"tuberculosis-risk-assessment","status":"publish","type":"page","link":"https:\/\/blossomhc.net\/tuberculosis-risk-assessment\/","title":{"rendered":"Tuberculosis Risk Assessment"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_chrome gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_4' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Tuberculosis Risk Assessment<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_4'  action='\/wp-json\/wp\/v2\/pages\/918' data-formid='4' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_4' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_4_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-two-thirds field_sublabel_hidden_label gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_1\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_4_1'>\n                            \n                            <span id='input_4_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_4_1_3' value=''   aria-required='false'   placeholder='Full Name'  \/>\n                                                    <label for='input_4_1_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><fieldset id=\"field_4_4\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_4\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >DOB<\/legend><div id='input_4_4' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_4_4_1_container'>\n                                            <input type='number' maxlength='2' name='input_4[]' id='input_4_4_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_4_4_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_4_4_2_container'>\n                                            <input type='number' maxlength='2' name='input_4[]' id='input_4_4_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_4_4_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_4_4_3_container'>\n                                            <input type='number' maxlength='4' name='input_4[]' id='input_4_4_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2025' step='1'\/>\n                                            <label for='input_4_4_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_4_35\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_35\" ><label class='gfield_label gform-field-label' for='input_4_35'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_35' id='input_4_35' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_4_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_3\" ><label class='gfield_label gform-field-label' for='input_4_3'>Last 4 of SS#<\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_4_3' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_4_5\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_5\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Have you traveled out of the country recently and remained  there for more than 1 month?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_4_5'><div class='gchoice gchoice_4_5_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.1' type='checkbox'  value='Yes'  id='choice_4_5_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_5_1' id='label_4_5_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_5_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.2' type='checkbox'  value='No'  id='choice_4_5_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_5_2' id='label_4_5_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_6\" ><label class='gfield_label gform-field-label' for='input_4_6'>Please specify country of travel<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_4_6' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_4_7\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_7\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Current or planned immunosuppression,  including HIV infection, receipt of an organ transplant, treatment with an TNF-alpha antagonist (e.g., infliximab, etanercept, or other), chronic steroids (equivalent of prednisone \udbc0\udc10 15 mg\/day for  \udbc0\udc10 1 month) or other immunosuppressive medication<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_4_7'><div class='gchoice gchoice_4_7_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.1' type='checkbox'  value='Yes'  id='choice_4_7_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_7_1' id='label_4_7_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_7_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_7.2' type='checkbox'  value='No'  id='choice_4_7_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_7_2' id='label_4_7_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_8\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_8\" ><label class='gfield_label gform-field-label' for='input_4_8'>Please explain<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_4_8' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_4_9\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_9\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Close contact with someone who has had TB  disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_4_9'><div class='gchoice gchoice_4_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.1' type='checkbox'  value='Yes'  id='choice_4_9_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_9_1' id='label_4_9_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_9_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.2' type='checkbox'  value='No'  id='choice_4_9_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_9_2' id='label_4_9_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_10\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_10\" ><label class='gfield_label gform-field-label' for='input_4_10'>Please explain<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_4_10' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_4_11\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_11\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Treatment for latent TB infection<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_4_11'><div class='gchoice gchoice_4_11_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.1' type='checkbox'  value='Yes'  id='choice_4_11_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_11_1' id='label_4_11_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_11_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.2' type='checkbox'  value='No'  id='choice_4_11_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_11_2' id='label_4_11_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_12\" ><label class='gfield_label gform-field-label' for='input_4_12'>Please explain<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_4_12' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_4_13\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_13\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Prior diagnosis of active TB or latent TB  infection or a positive skin test or positive blood  test for TB<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_4_13'><div class='gchoice gchoice_4_13_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.1' type='checkbox'  value='Yes'  id='choice_4_13_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_13_1' id='label_4_13_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_13_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.2' type='checkbox'  value='No'  id='choice_4_13_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_13_2' id='label_4_13_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_14\" ><label class='gfield_label gform-field-label' for='input_4_14'>Please explain<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_4_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_4_15\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_15\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Treatment with medication for TB or for a  positive TB test<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_4_15'><div class='gchoice gchoice_4_15_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.1' type='checkbox'  value='Yes'  id='choice_4_15_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_15_1' id='label_4_15_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_15_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.2' type='checkbox'  value='No'  id='choice_4_15_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_15_2' id='label_4_15_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_16\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_16\" ><label class='gfield_label gform-field-label' for='input_4_16'>Please explain<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_4_16' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_4_17\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_17\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Productive cough for more than 3 weeks<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_4_17'><div class='gchoice gchoice_4_17_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.1' type='checkbox'  value='Yes'  id='choice_4_17_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_17_1' id='label_4_17_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_17_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.2' type='checkbox'  value='No'  id='choice_4_17_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_17_2' id='label_4_17_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_18\" ><label class='gfield_label gform-field-label' for='input_4_18'>Please explain<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_4_18' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_4_19\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_19\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Coughing up blood<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_4_19'><div class='gchoice gchoice_4_19_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.1' type='checkbox'  value='Yes'  id='choice_4_19_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_19_1' id='label_4_19_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_19_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.2' type='checkbox'  value='No'  id='choice_4_19_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_19_2' id='label_4_19_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_20\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_20\" ><label class='gfield_label gform-field-label' for='input_4_20'>Please explain<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_4_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_4_21\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_21\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Unexplained Weight Loss<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_4_21'><div class='gchoice gchoice_4_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='Yes'  id='choice_4_21_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_21_1' id='label_4_21_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='No'  id='choice_4_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_21_2' id='label_4_21_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_22\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_22\" ><label class='gfield_label gform-field-label' for='input_4_22'>Please explain<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_4_22' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_4_23\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_23\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Fever, chills, or drenching night sweats for no  known reason<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_4_23'><div class='gchoice gchoice_4_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='Yes'  id='choice_4_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_23_1' id='label_4_23_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='No'  id='choice_4_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_23_2' id='label_4_23_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_24\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_24\" ><label class='gfield_label gform-field-label' for='input_4_24'>Please explain<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_4_24' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_4_25\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_25\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Persistent shortness of breath<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_4_25'><div class='gchoice gchoice_4_25_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.1' type='checkbox'  value='Yes'  id='choice_4_25_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_25_1' id='label_4_25_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_25_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.2' type='checkbox'  value='No'  id='choice_4_25_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_25_2' id='label_4_25_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_26\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_26\" ><label class='gfield_label gform-field-label' for='input_4_26'>Please explain<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_4_26' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_4_27\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_27\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Unexplained fatigue for more than 3 weeks<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_4_27'><div class='gchoice gchoice_4_27_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.1' type='checkbox'  value='Yes'  id='choice_4_27_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_27_1' id='label_4_27_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_27_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.2' type='checkbox'  value='No'  id='choice_4_27_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_27_2' id='label_4_27_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_28\" ><label class='gfield_label gform-field-label' for='input_4_28'>Please explain<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_4_28' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_4_29\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_29\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Chest pain<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_4_29'><div class='gchoice gchoice_4_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.1' type='checkbox'  value='Yes'  id='choice_4_29_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_29_1' id='label_4_29_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_29_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.2' type='checkbox'  value='No'  id='choice_4_29_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_29_2' id='label_4_29_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_30\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_30\" ><label class='gfield_label gform-field-label' for='input_4_30'>Please explain<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_4_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_4_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-three-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_33\" ><label class='gfield_label gform-field-label' for='input_4_33'>Employee Signature<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_4_33' 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