{"id":244,"date":"2016-05-26T10:48:46","date_gmt":"2016-05-26T10:48:46","guid":{"rendered":"http:\/\/www.kerribean.com\/jan\/?page_id=244"},"modified":"2017-11-02T03:48:27","modified_gmt":"2017-11-02T03:48:27","slug":"medical-questionnaire","status":"publish","type":"page","link":"https:\/\/www.kerribean.com\/jan\/medical-questionnaire\/","title":{"rendered":"Medical Questionnaire"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-fullwidth-1  fusion-parallax-none hundred-percent-fullwidth fusion-equal-height-columns\" style=\"border-color:#eae9e9;border-bottom-width: 0px;border-top-width: 0px;border-bottom-style: solid;border-top-style: solid;padding-bottom:0px;padding-top:0px;padding-left:0px;padding-right:0px;background-color:#ffffff;\"><style type=\"text\/css\" scoped=\"scoped\">.fusion-fullwidth-1, .fusion-fullwidth-1.fusion-section-separator {\n                        padding-left: 0px !important;\n                        padding-right: 0px !important;\n                    }<\/style><div class=\"fusion-row\"><div class=\"fusion-one-full fusion-layout-column fusion-column-last fusion-spacing-yes servwrapper\" style=\"margin-top:0px;margin-bottom:0px;\"><div class=\"fusion-column-wrapper\" style=\"padding:0px;\"><span class=\"fusion-imageframe imageframe-none imageframe-1 hover-type-none servhead\"> <img alt=\"\" class=\"img-responsive\"\/><\/span><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-fullwidth-2  fusion-parallax-none hundred-percent-fullwidth fusion-equal-height-columns\" style=\"border-color:#eae9e9;border-bottom-width: 0px;border-top-width: 0px;border-bottom-style: solid;border-top-style: solid;padding-bottom:0px;padding-top:0px;padding-left:0px;padding-right:0px;background-color:#ffffff;\"><style type=\"text\/css\" scoped=\"scoped\">.fusion-fullwidth-2, .fusion-fullwidth-2.fusion-section-separator {\n                        padding-left: 0px !important;\n                        padding-right: 0px !important;\n                    }<\/style><div class=\"fusion-row\"><div class=\"fusion-title title fusion-sep-none fusion-title-size-one pagettl\" style=\"margin-top:0px;margin-bottom:31px;\"><h1 class=\"title-heading-left\">Medical Questionnaire<\/h1><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-fullwidth-3  fusion-parallax-none nonhundred-percent-fullwidth\" style=\"border-color:#eae9e9;border-bottom-width: 0px;border-top-width: 0px;border-bottom-style: solid;border-top-style: solid;padding-bottom:20px;padding-top:20px;padding-left:;padding-right:;background-color:rgba(255,255,255,0);\"><div class=\"fusion-row\"><div class=\"fusion-one-full fusion-layout-column fusion-column-last fusion-spacing-yes\" style=\"margin-top:0px;margin-bottom:20px;\"><div class=\"fusion-column-wrapper\"><div class=\"fusion-title title fusion-sep-none fusion-title-size-one\" style=\"margin-top:0px;margin-bottom:31px;\"><h1 class=\"title-heading-left\">No Obligation Enquiry Form<\/h1><\/div><div class=\"fusion-title title fusion-sep-none fusion-title-size-three\" style=\"margin-top:0px;margin-bottom:31px;\"><h3 class=\"title-heading-left\"><em>Please complete all fields and click Submit. We will reply to you as soon as we are able.<\/em><\/h3><\/div>\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f299-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/jan\/wp-json\/wp\/v2\/pages\/244#wpcf7-f299-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"299\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.9.5\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f299-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<h1>1. Your Contact Details\n<\/h1>\n<h3>Name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span>\n<\/h3>\n<h3>Address<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"address\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Your Full Address ...\" name=\"address\"><\/textarea><\/span>\n<\/h3>\n<h3>Country<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"country\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"country\" \/><\/span>\n<\/h3>\n<h3>Email<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-email\" \/><\/span>\n<\/h3>\n<h3>Phone Number<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mq-tel\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"include dailing codes...\" value=\"\" type=\"tel\" name=\"mq-tel\" \/><\/span>\n<\/h3>\n<h1>2. Family Doctor Contact Details\n<\/h1>\n<h3>Name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"doc-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Doctors Name...\" value=\"\" type=\"text\" name=\"doc-name\" \/><\/span>\n<\/h3>\n<h3>Company \/ Practise Name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"company-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Company Name...\" value=\"\" type=\"text\" name=\"company-name\" \/><\/span>\n<\/h3>\n<h3>Address<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"doc-add\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Enter Full Address ...\" name=\"doc-add\"><\/textarea><\/span>\n<\/h3>\n<h3>Country<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"doc-country\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"doc-country\" \/><\/span>\n<\/h3>\n<h3>Phone Number<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"doc-tel\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"include dailing codes...\" value=\"\" type=\"tel\" name=\"doc-tel\" \/><\/span>\n<\/h3>\n<h1>3. What is your height in feet and inches?\n<\/h1>\n<h3><span class=\"wpcf7-form-control-wrap\" data-name=\"height\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Remove shoes before measuring.\" value=\"\" type=\"text\" name=\"height\" \/><\/span>\n<\/h3>\n<h1>4. What is your current weight?\n<\/h1>\n<h3><span class=\"wpcf7-form-control-wrap\" data-name=\"weight\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"In pounds ...\" value=\"\" type=\"text\" name=\"weight\" \/><\/span>\n<\/h3>\n<h1>5. What is your gender?\n<\/h1>\n<h3><span class=\"wpcf7-form-control-wrap\" data-name=\"gender\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"gender\" value=\"Female\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"gender\" value=\"Male\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/label><\/span><\/span><\/span>\n<\/h3>\n<h1>6. What surgical procedures would you like?\n<\/h1>\n<h3><strong><em>Pick one from the list.<\/em><\/strong><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"procedure\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"procedure\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Aesthetic surgery?\">Aesthetic surgery?<\/option><option value=\"Reconstruction?\">Reconstruction?<\/option><option value=\"Hand\/Wrist\/Elbow?\">Hand\/Wrist\/Elbow?<\/option><option value=\"Other?\">Other?<\/option><\/select><\/span>\n<\/h3>\n<h1>7. Is this a medical vacation?\n<\/h1>\n<h3><span class=\"wpcf7-form-control-wrap\" data-name=\"vacation\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"vacation\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"vacation\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n<\/h3>\n<h1>8. Has any family member suffered from any of the following ailments?\n<\/h1>\n<h3><strong><em>Please select all that apply.<\/em><\/strong><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"famhist\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"famhist[]\" value=\"Bleeding Disorder\" \/><span class=\"wpcf7-list-item-label\">Bleeding Disorder<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"famhist[]\" value=\"Heart Disease\" \/><span class=\"wpcf7-list-item-label\">Heart Disease<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"famhist[]\" value=\"High Cholesterol\" \/><span class=\"wpcf7-list-item-label\">High Cholesterol<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"famhist[]\" value=\"Hypertension\" \/><span class=\"wpcf7-list-item-label\">Hypertension<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"famhist[]\" value=\"Type 1 Diabetes\" \/><span class=\"wpcf7-list-item-label\">Type 1 Diabetes<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"famhist[]\" value=\"Type 2 Diabetes\" \/><span class=\"wpcf7-list-item-label\">Type 2 Diabetes<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"famhist[]\" value=\"None of my family members suffers from any of these ailments\" \/><span class=\"wpcf7-list-item-label\">None of my family members suffers from any of these ailments<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"famhist[]\" value=\"Prefer not to answer\" \/><span class=\"wpcf7-list-item-label\">Prefer not to answer<\/span><\/label><\/span><\/span><\/span>\n<\/h3>\n<h1>9. Do you suffer from any of the following ailments?\n<\/h1>\n<h3><strong><em>Please select all that apply.<\/em><\/strong><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ailments\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"ailments[]\" value=\"Adrenal Insufficiency\" \/><span class=\"wpcf7-list-item-label\">Adrenal Insufficiency<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"ailments[]\" value=\"Allergies\" \/><span class=\"wpcf7-list-item-label\">Allergies<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"ailments[]\" value=\"Bleeding Disorder\" \/><span class=\"wpcf7-list-item-label\">Bleeding Disorder<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"ailments[]\" value=\"Deep-vein Thrombsis\" \/><span class=\"wpcf7-list-item-label\">Deep-vein Thrombsis<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"ailments[]\" value=\"Diabetes\" \/><span class=\"wpcf7-list-item-label\">Diabetes<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"ailments[]\" value=\"Heart Disease\" \/><span class=\"wpcf7-list-item-label\">Heart Disease<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"ailments[]\" value=\"Hepatitis B\" \/><span class=\"wpcf7-list-item-label\">Hepatitis B<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"ailments[]\" value=\"Hepatitis C\" \/><span class=\"wpcf7-list-item-label\">Hepatitis C<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"ailments[]\" value=\"HIV\" \/><span class=\"wpcf7-list-item-label\">HIV<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"ailments[]\" value=\"Hypertension\" \/><span class=\"wpcf7-list-item-label\">Hypertension<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"ailments[]\" value=\"Hyperthyroidism\" \/><span class=\"wpcf7-list-item-label\">Hyperthyroidism<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"ailments[]\" value=\"Hypothyroidism\" \/><span class=\"wpcf7-list-item-label\">Hypothyroidism<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"ailments[]\" value=\"Keloid\" \/><span class=\"wpcf7-list-item-label\">Keloid<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"ailments[]\" value=\"Have you ever had a cardiac arrest?\" \/><span class=\"wpcf7-list-item-label\">Have you ever had a cardiac arrest?<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"ailments[]\" value=\"Are you currently on medication?\" \/><span class=\"wpcf7-list-item-label\">Are you currently on medication?<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"ailments[]\" value=\"Do you drink alcohol?\" \/><span class=\"wpcf7-list-item-label\">Do you drink alcohol?<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"ailments[]\" value=\"Do you smoke cigarettes?\" \/><span class=\"wpcf7-list-item-label\">Do you smoke cigarettes?<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"ailments[]\" value=\"Are you pregnant?\" \/><span class=\"wpcf7-list-item-label\">Are you pregnant?<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"ailments[]\" value=\"Do you plan to have children?\" \/><span class=\"wpcf7-list-item-label\">Do you plan to have children?<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"ailments[]\" value=\"Are you breast feeding?\" \/><span class=\"wpcf7-list-item-label\">Are you breast feeding?<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"ailments[]\" value=\"Do you plan to breast feed?\" \/><span class=\"wpcf7-list-item-label\">Do you plan to breast feed?<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"ailments[]\" value=\"I do not suffer from any of these ailments\" \/><span class=\"wpcf7-list-item-label\">I do not suffer from any of these ailments<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"ailments[]\" value=\"Prefer not to answer\" \/><span class=\"wpcf7-list-item-label\">Prefer not to answer<\/span><\/label><\/span><\/span><\/span>\n<\/h3>\n<h1>10. If you have had a keloid please state where on your body and attach a picture of it.\n<\/h1>\n<h3><span class=\"wpcf7-form-control-wrap\" data-name=\"keloid\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Where on body? or n\/a\" value=\"\" type=\"text\" name=\"keloid\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"kel-file\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".gif,.png,.jpg,.jpeg\" aria-invalid=\"false\" type=\"file\" name=\"kel-file\" \/><\/span>\n<\/h3>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Send\" \/>\n<\/p><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"0\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n<div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"100-width.php","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"class_list":["post-244","page","type-page","status-publish","hentry"],"jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/www.kerribean.com\/jan\/wp-json\/wp\/v2\/pages\/244","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.kerribean.com\/jan\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.kerribean.com\/jan\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.kerribean.com\/jan\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.kerribean.com\/jan\/wp-json\/wp\/v2\/comments?post=244"}],"version-history":[{"count":9,"href":"https:\/\/www.kerribean.com\/jan\/wp-json\/wp\/v2\/pages\/244\/revisions"}],"predecessor-version":[{"id":2016,"href":"https:\/\/www.kerribean.com\/jan\/wp-json\/wp\/v2\/pages\/244\/revisions\/2016"}],"wp:attachment":[{"href":"https:\/\/www.kerribean.com\/jan\/wp-json\/wp\/v2\/media?parent=244"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}