{"id":546,"date":"2018-01-11T01:47:55","date_gmt":"2018-01-11T01:47:55","guid":{"rendered":"http:\/\/www.kaortho.com\/nouveau-patient\/formulaire-medical-pour-adulte\/"},"modified":"2020-05-26T17:27:50","modified_gmt":"2020-05-26T17:27:50","slug":"formulaire-medical","status":"publish","type":"page","link":"https:\/\/www.kaortho.com\/fr\/nouveau-patient\/formulaire-medical\/","title":{"rendered":"Formulaire m\u00e9dical"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row css_animation=\u00a0\u00bb\u00a0\u00bb row_type=\u00a0\u00bbrow\u00a0\u00bb use_row_as_full_screen_section=\u00a0\u00bbno\u00a0\u00bb type=\u00a0\u00bbfull_width\u00a0\u00bb angled_section=\u00a0\u00bbno\u00a0\u00bb text_align=\u00a0\u00bbleft\u00a0\u00bb background_image_as_pattern=\u00a0\u00bbwithout_pattern\u00a0\u00bb css=\u00a0\u00bb.vc_custom_1590514068059{margin-bottom: 50px !important;}\u00a0\u00bb][vc_column][vc_column_text]<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar 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3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_3' style='display:none'><div id='gf_3' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">Formulaire m\u00e9dical<\/h3>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_3' id='gform_3'  action='\/fr\/wp-json\/wp\/v2\/pages\/546#gf_3' data-formid='3' novalidate> \r\n <input type='hidden' class='gforms-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/>\n                        <div class='gform-body gform_body'><ul id='gform_fields_3' class='gform_fields right_label form_sublabel_below description_below validation_below'><li id=\"field_3_12\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Infomation de base<\/h2><\/li><li id=\"field_3_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_1'>\n                            \n                            <span id='input_3_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_3_1_3' value=''   aria-required='true'     \/ data-admin-label=\"Nom\">\n                                                    <label for='input_3_1_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_3_1_6' value=''   aria-required='true'     \/ data-admin-label=\"Nom\">\n                                                    <label for='input_3_1_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_3_20\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_20'>Sexe<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_20' id='input_3_20' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\"  data-admin-label=\"Sexe\"><option value='' ><\/option><option value='Male' >Male<\/option><option value='Femelle' >Femelle<\/option><\/select><\/div><\/li><li id=\"field_3_3\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Adresse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_zip ginput_container_address gform-grid-row' id='input_3_3' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_3_1_container' >\n                                        <input type='text' name='input_3.1' id='input_3_3_1' value=''    aria-required='true'    \/ data-admin-label=\"Adresse\">\n                                        <label for='input_3_3_1' id='input_3_3_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse 1<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_3_3_2_container' >\n                                        <input type='text' name='input_3.2' id='input_3_3_2' value=''     aria-required='false'   \/ data-admin-label=\"Adresse\">\n                                        <label for='input_3_3_2' id='input_3_3_2_label' class='gform-field-label gform-field-label--type-sub '>Adresse 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_3_3_container' >\n                                    <input type='text' name='input_3.3' id='input_3_3_3' value=''    aria-required='true'    \/ data-admin-label=\"Adresse\">\n                                    <label for='input_3_3_3' id='input_3_3_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_3.4' id='input_3_3_4' value=''\/ data-admin-label=\"Adresse\"><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_3_3_5_container' >\n                                    <input type='text' name='input_3.5' id='input_3_3_5' value=''    aria-required='true'    \/ data-admin-label=\"Adresse\">\n                                    <label for='input_3_3_5' id='input_3_3_5_label' class='gform-field-label gform-field-label--type-sub '>Code Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_3.6' id='input_3_3_6' value='' \/ data-admin-label=\"Adresse\">\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_3_4\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_4'>T\u00e9l\u00e9phone \u00e0 domicile<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_3_4' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/ data-admin-label=\"T\u00e9l\u00e9phone \u00e0 domicile\"><\/div><\/li><li id=\"field_3_5\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_5'>T\u00e9l\u00e9phone au travail<\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_3_5' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/ data-admin-label=\"T\u00e9l\u00e9phone au travail\"><\/div><\/li><li id=\"field_3_6\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_6'>Courriel<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_6' id='input_3_6' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/ data-admin-label=\"Courriel\">\n                        <\/div><\/li><li id=\"field_3_7\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_7'>Date de naissance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_7' id='input_3_7' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='jj-mm-aaaa' aria-describedby=\"input_3_7_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/ data-admin-label=\"Date de naissance\">\n                            <span id='input_3_7_date_format' class='screen-reader-text'>JJ - MM - AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_7' class='gform_hidden' value='https:\/\/www.kaortho.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/ data-admin-label=\"Date de naissance\"><\/li><li id=\"field_3_8\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_8'>En cas d&#039;urgence , veuillez contacter:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_3_8' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/ data-admin-label=\"En cas d&#039;urgence , veuillez contacter:\"><\/div><\/li><li id=\"field_3_9\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_9'>Nom de votre dentiste<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_3_9' type='text' value='' class='medium'      aria-invalid=\"false\"   \/ data-admin-label=\"Nom de votre dentiste\"><\/div><\/li><li id=\"field_3_10\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_10'>Personne qui vous a r\u00e9f\u00e9r\u00e9<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_3_10' type='text' value='' class='medium'      aria-invalid=\"false\"   \/ data-admin-label=\"Personne qui vous a r\u00e9f\u00e9r\u00e9\"><\/div><\/li><li id=\"field_3_11\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_11'>Motif de votre visite<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_3_11' type='text' value='' class='medium'      aria-invalid=\"false\"   \/ data-admin-label=\"Motif de votre visite\"><\/div><\/li><li id=\"field_3_13\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Historique m\u00e9dical<\/h2><\/li><li id=\"field_3_17\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_17'>\u00cates-vous pr\u00e9sentement  suivi par un m\u00e9decin ?<\/label><div class='ginput_container ginput_container_select'><select name='input_17' id='input_3_17' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"\u00cates-vous pr\u00e9sentement  suivi par un m\u00e9decin ?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_15\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_15'>Le cas \u00e9ch\u00e9ant, veuillez fournir son nom et # de t\u00e9l.<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_3_15' type='text' value='' class='medium'      aria-invalid=\"false\"   \/ data-admin-label=\"Le cas \u00e9ch\u00e9ant, veuillez fournir son nom et # de t\u00e9l.\"><\/div><\/li><li id=\"field_3_16\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_16'>Prenez-vous des m\u00e9dicaments ou en avez-vous pris au cours  des six derniers mois ?<\/label><div class='ginput_container ginput_container_select'><select name='input_16' id='input_3_16' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Prenez-vous des m\u00e9dicaments ou en avez-vous pris au cours  des six derniers mois ?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_18\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_18'>Le cas \u00e9ch\u00e9ant, veuillez indiquer lesquels:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_18' id='input_3_18' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50' data-admin-label=\"Le cas \u00e9ch\u00e9ant, veuillez indiquer lesquels:\"><\/textarea><\/div><\/li><li id=\"field_3_19\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_19'>\u00cates-vous enceinte ?<\/label><div class='ginput_container ginput_container_select'><select name='input_19' id='input_3_19' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"\u00cates-vous enceinte ?\"><option value='' ><\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_3_21\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Avez-vous d\u00e9j\u00e0 souffert ou souffrez-vous de...<\/h2><\/li><li id=\"field_3_22\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_22'>Troubles cardiaques (infarctus, angine, probl\u00e8mes valvulaires, souffle) ?<\/label><div class='ginput_container ginput_container_select'><select name='input_22' id='input_3_22' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Troubles cardiaques (infarctus, angine, probl\u00e8mes valvulaires, souffle) ?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_23\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_23'>Fi\u00e8vre rhumatismale ?<\/label><div class='ginput_container ginput_container_select'><select name='input_23' id='input_3_23' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Fi\u00e8vre rhumatismale ?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_24\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_24'>Saignements prolong\u00e9s ?<\/label><div class='ginput_container ginput_container_select'><select name='input_24' id='input_3_24' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Saignements prolong\u00e9s ?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_25\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_25'>An\u00e9mie ?<\/label><div class='ginput_container ginput_container_select'><select name='input_25' id='input_3_25' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"An\u00e9mie ?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_26\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_26'>Tension art\u00e9rielle ?<\/label><div class='ginput_container ginput_container_select'><select name='input_26' id='input_3_26' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Tension art\u00e9rielle ?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_27\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_27'>Sinusites ou rhumes fr\u00e9quents ?<\/label><div class='ginput_container ginput_container_select'><select name='input_27' id='input_3_27' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Sinusites ou rhumes fr\u00e9quents ?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_28\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_28'>Tuberculose ou probl\u00e8mes pulmonaires ?<\/label><div class='ginput_container ginput_container_select'><select name='input_28' id='input_3_28' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Tuberculose ou probl\u00e8mes pulmonaires ?\"><option value='' selected='selected'><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_29\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_29'>Probl\u00e8me d&#039;estomac, troubles digestifs ?<\/label><div class='ginput_container ginput_container_select'><select name='input_29' id='input_3_29' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Probl\u00e8me d&#039;estomac, troubles digestifs ?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_30\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_30'>Probl\u00e8mes de foie (h\u00e9patite : virus A, B, C, cirrhose)?<\/label><div class='ginput_container ginput_container_select'><select name='input_30' id='input_3_30' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Probl\u00e8mes de foie (h\u00e9patite : virus A, B, C, cirrhose)?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_31\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_31'>Probl\u00e8mes r\u00e9naux?<\/label><div class='ginput_container ginput_container_select'><select name='input_31' id='input_3_31' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Probl\u00e8mes r\u00e9naux?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_32\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_32'>Diab\u00e8te ?<\/label><div class='ginput_container ginput_container_select'><select name='input_32' id='input_3_32' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Diab\u00e8te ?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_33\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_33'>Troubles thyro\u00efdiens ?<\/label><div class='ginput_container ginput_container_select'><select name='input_33' id='input_3_33' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Troubles thyro\u00efdiens ?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_34\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_34'>Maladies cutan\u00e9es?<\/label><div class='ginput_container ginput_container_select'><select name='input_34' id='input_3_34' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Maladies cutan\u00e9es?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_35\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_35'>Probl\u00e8mes oculaires ?<\/label><div class='ginput_container ginput_container_select'><select name='input_35' id='input_3_35' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Probl\u00e8mes oculaires ?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_36\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_36'>Arthrite ?<\/label><div class='ginput_container ginput_container_select'><select name='input_36' id='input_3_36' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Arthrite ?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_37\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_37'>\u00c9pilepsie ?<\/label><div class='ginput_container ginput_container_select'><select name='input_37' id='input_3_37' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"\u00c9pilepsie ?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_38\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_38'>Maux de t\u00eate fr\u00e9quents ?<\/label><div class='ginput_container ginput_container_select'><select name='input_38' id='input_3_38' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Maux de t\u00eate fr\u00e9quents ?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_39\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_39'>\u00c9tourdissements et\/ou \u00e9vanouissements ?<\/label><div class='ginput_container ginput_container_select'><select name='input_39' id='input_3_39' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"\u00c9tourdissements et\/ou \u00e9vanouissements ?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_40\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_40'>Maux d&#039;oreilles?<\/label><div class='ginput_container ginput_container_select'><select name='input_40' id='input_3_40' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Maux d&#039;oreilles?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_41\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_41'>Asthme?<\/label><div class='ginput_container ginput_container_select'><select name='input_41' id='input_3_41' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Asthme?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_42\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_42'>Apn\u00e9e du sommeil ?<\/label><div class='ginput_container ginput_container_select'><select name='input_42' id='input_3_42' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Apn\u00e9e du sommeil ?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_43\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_43'>\u00cates-vous fumeur ?<\/label><div class='ginput_container ginput_container_select'><select name='input_43' id='input_3_43' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"\u00cates-vous fumeur ?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_44\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_44'>Avez-vous d\u00e9j\u00e0 subi des traitements de radioth\u00e9rapie ou chimioth\u00e9rapie ?<\/label><div class='ginput_container ginput_container_select'><select name='input_44' id='input_3_44' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Avez-vous d\u00e9j\u00e0 subi des traitements de radioth\u00e9rapie ou chimioth\u00e9rapie ?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_45\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_45'>Avez-vous des proth\u00e8ses articulaires ?<\/label><div class='ginput_container ginput_container_select'><select name='input_45' id='input_3_45' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Avez-vous des proth\u00e8ses articulaires ?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_46\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_46'>Avez-vous des allergies \u00e0 la nourriture ou des m\u00e9dicaments?<\/label><div class='ginput_container ginput_container_select'><select name='input_46' id='input_3_46' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Avez-vous des allergies \u00e0 la nourriture ou des m\u00e9dicaments?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_47\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_47'>Le cas \u00e9ch\u00e9ant, veuillez pr\u00e9ciser:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_47' id='input_3_47' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50' data-admin-label=\"Le cas \u00e9ch\u00e9ant, veuillez pr\u00e9ciser:\"><\/textarea><\/div><\/li><li id=\"field_3_48\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_48'>Avez-vous une allergie au latex ou m\u00e9tal?<\/label><div class='ginput_container ginput_container_select'><select name='input_48' id='input_3_48' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Avez-vous une allergie au latex ou m\u00e9tal?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_49\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_49'>Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 hospitalis\u00e9 ou subi une intervention chirurgicale autre que dentaires?<\/label><div class='ginput_container ginput_container_select'><select name='input_49' id='input_3_49' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 hospitalis\u00e9 ou subi une intervention chirurgicale autre que dentaires?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_50\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_50'>Le cas \u00e9ch\u00e9ant, quel type d&#039;intervention et quand a-t-elle eu lieu?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_50' id='input_3_50' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50' data-admin-label=\"Le cas \u00e9ch\u00e9ant, quel type d&#039;intervention et quand a-t-elle eu lieu?\"><\/textarea><\/div><\/li><li id=\"field_3_51\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_51'>Commentaires<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_51' id='input_3_51' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50' data-admin-label=\"Commentaires\"><\/textarea><\/div><\/li><li id=\"field_3_52\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Historique dentaire<\/h2><\/li><li id=\"field_3_53\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_53'>Derni\u00e8re visite chez le dentiste<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_53' id='input_3_53' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\"  data-admin-label=\"Derni\u00e8re visite chez le dentiste\"><option value='' ><\/option><option value='0-6 mois' >0-6 mois<\/option><option value='6-12 mois' >6-12 mois<\/option><option value='12+ mois' >12+ mois<\/option><\/select><\/div><\/li><li id=\"field_3_54\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_54'>Traitements re\u00e7us<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_54' id='input_3_54' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50' data-admin-label=\"Traitements re\u00e7us\"><\/textarea><\/div><\/li><li id=\"field_3_55\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_55'>Souffrez-vous de douleur bucco-dentaire ou articulaire?<\/label><div class='ginput_container ginput_container_select'><select name='input_55' id='input_3_55' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Souffrez-vous de douleur bucco-dentaire ou articulaire?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_56\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_56'>Est-ce que des dents permanentes ont d\u00e9j\u00e0 \u00e9t\u00e9 extraites?<\/label><div class='ginput_container ginput_container_select'><select name='input_56' id='input_3_56' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Est-ce que des dents permanentes ont d\u00e9j\u00e0 \u00e9t\u00e9 extraites?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_60\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_60'>Avez-vous d\u00e9j\u00e0 suc\u00e9 votre pouce ou un autre de vos doigts?<\/label><div class='ginput_container ginput_container_select'><select name='input_60' id='input_3_60' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Avez-vous d\u00e9j\u00e0 suc\u00e9 votre pouce ou un autre de vos doigts?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_57\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_57'>Y a-t-il des dents qui ont \u00e9t\u00e9 cass\u00e9es ou ab\u00eem\u00e9es suite \u00e0 un accident?<\/label><div class='ginput_container ginput_container_select'><select name='input_57' id='input_3_57' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Y a-t-il des dents qui ont \u00e9t\u00e9 cass\u00e9es ou ab\u00eem\u00e9es suite \u00e0 un accident?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_58\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_58'>Pr\u00e9sentez-vous des blessures au visage ou \u00e0 la t\u00eate?<\/label><div class='ginput_container ginput_container_select'><select name='input_58' id='input_3_58' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Pr\u00e9sentez-vous des blessures au visage ou \u00e0 la t\u00eate?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_59\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_59'>Souffrez-vous de probl\u00e8mes d&#039;\u00e9locution?<\/label><div class='ginput_container ginput_container_select'><select name='input_59' id='input_3_59' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Souffrez-vous de probl\u00e8mes d&#039;\u00e9locution?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_62\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_62'>Le cas \u00e9ch\u00e9ant, jusqu&#039;\u00e0 quel \u00e2ge?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_3_62' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/ data-admin-label=\"Le cas \u00e9ch\u00e9ant, jusqu&#039;\u00e0 quel \u00e2ge?\"><\/div><\/li><li id=\"field_3_61\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_61'>Respirez-vous principalement par la bouche?<\/label><div class='ginput_container ginput_container_select'><select name='input_61' id='input_3_61' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Respirez-vous principalement par la bouche?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_63\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_63'>Avez-vous l&#039;habitude de pousser votre langue contre vos dents?<\/label><div class='ginput_container ginput_container_select'><select name='input_63' id='input_3_63' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Avez-vous l&#039;habitude de pousser votre langue contre vos dents?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_64\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_64'>Avez-vous l&#039;habitude de grincer ou de serrer les dents?<\/label><div class='ginput_container ginput_container_select'><select name='input_64' id='input_3_64' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Avez-vous l&#039;habitude de grincer ou de serrer les dents?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_65\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_65'>Jouez-vous d&#039;un instrument de musique \u00e0 vent?<\/label><div class='ginput_container ginput_container_select'><select name='input_65' id='input_3_65' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Jouez-vous d&#039;un instrument de musique \u00e0 vent?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_66\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_66'>Avez-vous d\u00e9j\u00e0 vu un autre orthodontiste?<\/label><div class='ginput_container ginput_container_select'><select name='input_66' id='input_3_66' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Avez-vous d\u00e9j\u00e0 vu un autre orthodontiste?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_67\" class=\"gfield 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ginput_container_select'><select name='input_70' id='input_3_70' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Est-ce que votre m\u00e2choire \u00e9met des craquements ou vous cause de la douleur?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_69\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Avez-vous d\u00e9j\u00e0 eu recours aux soins\/services dentaires suivants...<\/h2><\/li><li id=\"field_3_68\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_68'>D\u00e9monstration d&#039;hygi\u00e8ne bucco-dentaire?<\/label><div class='ginput_container ginput_container_select'><select name='input_68' id='input_3_68' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"D\u00e9monstration d&#039;hygi\u00e8ne bucco-dentaire?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_71\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_71'>Traitement des gencives?<\/label><div class='ginput_container ginput_container_select'><select name='input_71' id='input_3_71' class='medium gfield_select'     aria-invalid=\"false\"  data-admin-label=\"Traitement des gencives?\"><option value='' ><\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_3_72\" class=\"gfield gfield--type-select field_sublabel_below 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