{"id":3788,"date":"2021-05-30T20:00:43","date_gmt":"2021-05-31T00:00:43","guid":{"rendered":"https:\/\/www.centredentairegriffin.com\/forms\/medical-form\/"},"modified":"2022-03-15T06:18:11","modified_gmt":"2022-03-15T10:18:11","slug":"formulaire-medical","status":"publish","type":"page","link":"https:\/\/vjwq067yt6d.c.updraftclone.com\/fr\/formulaires\/formulaire-medical\/","title":{"rendered":"Formulaire m\u00e9dical"},"content":{"rendered":"<p><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:0px;--awb-padding-bottom:40px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1320.8px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-margin-top-large:0px;--awb-spacing-right-large:0%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:5.76%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div ><a class=\"fusion-button button-flat button-xlarge button-custom fusion-button-default button-1 fusion-button-default-span fusion-button-default-type\" style=\"--button_accent_color:#656a70;--button_accent_hover_color:#6b6b6b;--button_border_hover_color:#ffffff;--button_gradient_top_color:rgba(0,0,0,0);--button_gradient_bottom_color:rgba(0,0,0,0);--button_gradient_top_color_hover:rgba(40,45,51,0.1);--button_gradient_bottom_color_hover:rgba(40,45,51,0.1);\" target=\"_self\" href=\"https:\/\/vjwq067yt6d.c.updraftclone.com\/fr\/formulaires\/\"><i class=\"fa-arrow-left fas awb-button__icon awb-button__icon--default button-icon-left\" aria-hidden=\"true\"><\/i><span class=\"fusion-button-text awb-button__text awb-button__text--default\">RETOURNER AU FORMULAIRES<\/span><\/a><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1320.8px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:25px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:25px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f3567-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"3567\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/fr\/wp-json\/wp\/v2\/pages\/3788#wpcf7-f3567-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"3567\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.6\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f3567-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/><input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:3567,&quot;conditions&quot;:[{&quot;then_field&quot;:&quot;show-dental-insurance&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;mf-dental-insurance-fr&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;oui&quot;}]},{&quot;then_field&quot;:&quot;show-physician&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;mf-history-under-care-fr&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;oui&quot;}]},{&quot;then_field&quot;:&quot;show-hospitalization&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;mf-history-hospitalized-2-years-fr&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;oui&quot;}]},{&quot;then_field&quot;:&quot;show-tobacco&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;mf-history-tobacco-use-fr&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;oui&quot;}]},{&quot;then_field&quot;:&quot;show-pregnant&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;mf-history-pregnant-fr&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;oui&quot;}]},{&quot;then_field&quot;:&quot;show-infection&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;mf-history-infections-by-blood-fr&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;oui&quot;}]},{&quot;then_field&quot;:&quot;show-cancer&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;mf-history-cancer-fr&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;oui&quot;}]},{&quot;then_field&quot;:&quot;show-transplant&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;mf-history-transplant-fr&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;oui&quot;}]},{&quot;then_field&quot;:&quot;show-prostheses&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;mf-history-prostheses-fr&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;oui&quot;}]},{&quot;then_field&quot;:&quot;show-homeopathic&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;mf-history-homeopathic-fr&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;oui&quot;}]},{&quot;then_field&quot;:&quot;show-charge&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;mf-person-in-charge-fr&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;&quot;}]}],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false,&quot;repeater_remove_button&quot;:&quot;bottom&quot;,&quot;notice_dismissed_rollback-cf7-5.9.2&quot;:true}}\" \/><input type=\"hidden\" name=\"redirect_nonce\" value=\"7b7bde6c7a\" \/><input type=\"hidden\" name=\"wpcf7cfpdf_hidden_name\" value=\"QM-mf-last-name-fr-mf-first-name-fr\" \/><input type=\"hidden\" name=\"wpcf7cfpdf_hidden_reference\" value=\"202128f5\" \/><input type=\"hidden\" name=\"wpcf7cfpdf_hidden_date\" value=\"6June2026\" \/>\n<\/fieldset>\n<div class=\"sg-container\">\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-6\">\n\t\t\t<p><label>Nom de famille <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr> <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-last-name-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-last-name-fr\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-6\">\n\t\t\t<p><label>Pr\u00e9nom <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-first-name-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-first-name-fr\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Date naissance <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-date-birth-fr\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"mf-date-birth-fr\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-6\">\n\t\t\t<p><label>No assurance maladie <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-health-number-fr\"><input size=\"40\" maxlength=\"14\" class=\"wpcf7-form-control wpcf7-text\" id=\"nas\" aria-invalid=\"false\" placeholder=\"____ ____ ____\" value=\"\" type=\"text\" name=\"mf-health-number-fr\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-6\">\n\t\t\t<p><label>Expiration <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-health-number-exp-fr\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"mf-health-number-exp-fr\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-6\">\n\t\t\t<p><label>Adresse <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-address-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-address-fr\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-6\">\n\t\t\t<p><label>Ville <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-city-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-city-fr\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-6\">\n\t\t\t<p><label>App. <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-app-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-app-fr\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-6\">\n\t\t\t<p><label>Code postal <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-postal-code-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-postal-code-fr\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-6\">\n\t\t\t<p><label>Tel - maison <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-phone-home-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"mf-phone-home-fr\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-6\">\n\t\t\t<p><label>Tel - travail <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-phone-work-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"mf-phone-work-fr\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-6\">\n\t\t\t<p><label>Tel - cellulaire <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-phone-cellular-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"mf-phone-cellular-fr\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-6\">\n\t\t\t<p><label>R\u00e9f\u00e9r\u00e9 par <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-referred-by-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-referred-by-fr\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Nom du responsable (si le patient est mineur) <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-person-in-charge-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-person-in-charge-fr\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div data-id=\"show-charge\" data-orig_data_id=\"show-charge\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<div class=\"sg-row\">\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>R\u00f4le<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-person-in-charge-role-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-person-in-charge-role-fr\" value=\"P\u00e8re\" \/><span class=\"wpcf7-list-item-label\">P\u00e8re<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"mf-person-in-charge-role-fr\" value=\"M\u00e8re\" \/><span class=\"wpcf7-list-item-label\">M\u00e8re<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"mf-person-in-charge-role-fr\" value=\"Tuteur\" \/><span class=\"wpcf7-list-item-label\">Tuteur<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-person-in-charge-role-fr\" value=\"Autre\" \/><span class=\"wpcf7-list-item-label\">Autre<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-6\">\n\t\t\t<p><label>Courriel <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-email-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"mf-email-fr\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-6\">\n\t\t\t<p><label>Occupation <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-occupation-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-occupation-fr\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Assurance dentaire<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-dental-insurance-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-dental-insurance-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-dental-insurance-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div data-id=\"show-dental-insurance\" data-orig_data_id=\"show-dental-insurance\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<div class=\"sg-row\">\n\t\t\t<div class=\"sg-col-6\">\n\t\t\t\t<p><label>Compagnie <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-company-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-company-fr\" \/><\/span> <\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"sg-col-6\">\n\t\t\t\t<p><label>No police <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-policy-num-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-policy-num-fr\" \/><\/span> <\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"sg-row\">\n\t\t\t<div class=\"sg-col-6\">\n\t\t\t\t<p><label>No certificat <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-certificate-num-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-certificate-num-fr\" \/><\/span> <\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"sg-col-6\">\n\t\t\t\t<p><label>Nom de l\u2019assur\u00e9 <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-name-of-insured-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-name-of-insured-fr\" \/><\/span> <\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"sg-row\">\n\t\t\t<div class=\"sg-col-6\">\n\t\t\t\t<p><label>Date de nais. De l\u2019assur\u00e9 <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-date-birth-insured-fr\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"mf-date-birth-insured-fr\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"sg-container\">\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<h3>Histoire M\u00e9dicale\n\t\t\t<\/h3>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>\u00cates-vous pr\u00e9sentement sous les soins d\u2019un m\u00e9decin ?<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-under-care-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-under-care-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-under-care-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div data-id=\"show-physician\" data-orig_data_id=\"show-physician\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<div class=\"sg-row\">\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Nom de votre m\u00e9decin :\u00a0<span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-doctor-name-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-doctor-name-fr\" \/><\/span> <\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Specialit\u00e9\u00a0: <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-speciality-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-speciality-fr\" \/><\/span> <\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Fr\u00e9quence des suivis : <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-frequency-follow-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-frequency-follow-fr\" \/><\/span> <\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Raison\u00a0: <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-follow-reason-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-follow-reason-fr\" \/><\/span> <\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Avez-vous \u00e9t\u00e9 hospitalis\u00e9 depuis les 2 derni\u00e8res ann\u00e9es ?\u00a0<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-hospitalized-2-years-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-hospitalized-2-years-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-hospitalized-2-years-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div data-id=\"show-hospitalization\" data-orig_data_id=\"show-hospitalization\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<div class=\"sg-row\">\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Raison\u00a0:<span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-hospitalized-reason-1-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-hospitalized-reason-1-fr\" \/><\/span> <\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Ann\u00e9e\u00a0:<span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-hospitalized-year-1-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-hospitalized-year-1-fr\" \/><\/span> <\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Raison\u00a0:<span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-hospitalized-reason-2-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-hospitalized-reason-2-fr\" \/><\/span> <\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Ann\u00e9e\u00a0:<span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-hospitalized-year-2-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-hospitalized-year-2-fr\" \/><\/span> <\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Raison\u00a0:<span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-hospitalized-reason-3-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-hospitalized-reason-3-fr\" \/><\/span> <\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Ann\u00e9e\u00a0:<span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-hospitalized-year-3-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-hospitalized-year-3-fr\" \/><\/span> <\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Faites-vous usage de tabac, Vapoteuse, Drogue, Alcool ?<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-tobacco-use-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-tobacco-use-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-tobacco-use-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div data-id=\"show-tobacco\" data-orig_data_id=\"show-tobacco\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<div class=\"sg-row\">\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Pr\u00e9cisez:<span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-tobacco-speficy-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-tobacco-speficy-fr\" \/><\/span> <\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Fr\u00e9quence de l\u2019usage :<span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-tobacco-frequency-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-tobacco-frequency-fr\" \/><\/span> <\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label><strong>Femme<\/strong><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>\u00cates-vous enceinte ?<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-pregnant-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-pregnant-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-pregnant-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div data-id=\"show-pregnant\" data-orig_data_id=\"show-pregnant\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<div class=\"sg-row\">\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Combien de semaines <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-pregnant-weeks-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-pregnant-weeks-fr\" \/><\/span> <\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Prenez -vous des anovulants ?<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-birth-control-pills-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-birth-control-pills-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-birth-control-pills-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>\u00cates-vous m\u00e9nopaus\u00e9e ?<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-menopausal-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-menopausal-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-menopausal-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Souffrez-vous ou avez-vous souffert de :<\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Troubles cardiaques (Infarctus, Angine, Arythmie, Souffle au coeur, Endocardite, Valvulopathie)<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-cardiac-disorders-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-cardiac-disorders-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-cardiac-disorders-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Troubles de la tension art\u00e9rielle (Haute ou Basse)<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-blood-pressure-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-blood-pressure-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-blood-pressure-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Troubles vasculaires (ACV, Thrombophl\u00e9bite)<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-vascular-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-vascular-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-vascular-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Troubles sanguins (H\u00e9mophilie, An\u00e9mie, Mononucl\u00e9ose)<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-blood-disorders-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-blood-disorders-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-blood-disorders-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Troubles pulmonaires (Asthme, Emphys\u00e8me, Tuberculose, MPOC)<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-pulmonary-disorders-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-pulmonary-disorders-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-pulmonary-disorders-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Troubles H\u00e9patiques (Jaunisse, H\u00e9patite A, B, C, Cirrhose)<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-liver-disorders-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-liver-disorders-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-liver-disorders-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Troubles digestifs (Reflux gastriques, Ulc\u00e8re d\u2019estomac, Maladie de Crohn)<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-digestive-disorders-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-digestive-disorders-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-digestive-disorders-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Troubles thyro\u00efdiens : (Hypothyro\u00efdie \/ Hyperthyro\u00efdie)<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-thyroid-disorders-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-thyroid-disorders-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-thyroid-disorders-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Troubles R\u00e9naux (Insuffisance r\u00e9nale, Pierre aux reins)<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-kidney-disorders-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-kidney-disorders-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-kidney-disorders-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Troubles neurologiques (\u00c9pilepsie, Parkinson)<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-neurological-disorders-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-neurological-disorders-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-neurological-disorders-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Scl\u00e9rose en plaques ?<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-multiple-sclerosis-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-multiple-sclerosis-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-multiple-sclerosis-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Troubles cognitifs et d\u2019apprentissage (THA, TDAH, Autisme, TED)<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-cognitive-learning-disorders-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-cognitive-learning-disorders-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-cognitive-learning-disorders-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Troubles psychiatriques (D\u00e9pression, Anxi\u00e9t\u00e9, Schizophr\u00e9nie, bipolarit\u00e9)<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-psychiatric-disorders-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-psychiatric-disorders-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-psychiatric-disorders-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Maladies inflammatoires (Arthrite, Arthrite Rhumato\u00efde)<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-inflammatory-diseases-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-inflammatory-diseases-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-inflammatory-diseases-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Ost\u00e9oporose ?<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-osteoporosis-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-osteoporosis-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-osteoporosis-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div data-id=\"show-osteoporosis\" data-orig_data_id=\"show-osteoporosis\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Pr\u00e9vention\/traitement (par comprim\u00e9s) ?<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-tablets-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-tablets-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-tablets-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Injection annuelle ou mensuelle ?<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-injection-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-injection-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-injection-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Infections transmissibles par le sang et la salive (ITSS\/MTS)<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-infections-by-blood-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-infections-by-blood-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-infections-by-blood-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div data-id=\"show-infection\" data-orig_data_id=\"show-infection\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Pr\u00e9cisez l\u2019infection :<span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-infections-by-blood-details-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-infections-by-blood-details-fr\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>\u00cates-vous s\u00e9ropositif (VIH)<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-hiv-positive-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-hiv-positive-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-hiv-positive-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Fi\u00e8vre Rhumatismale<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-rheumatic-fever-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-rheumatic-fever-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-rheumatic-fever-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Diab\u00e8te (Type I ou Type II)<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-diabetes-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-diabetes-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"mf-history-diabetes-fr\" value=\"Type I\" \/><span class=\"wpcf7-list-item-label\">Type I<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-diabetes-fr\" value=\"Type II\" \/><span class=\"wpcf7-list-item-label\">Type II<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Sinusite, Rhinite chronique<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-sinusitis-rhinitis-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-sinusitis-rhinitis-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-sinusitis-rhinitis-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Probl\u00e8me oculaire (Glaucome)<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-eye-problem-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-eye-problem-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-eye-problem-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Cancer (tumeur)<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-cancer-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-cancer-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-cancer-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div data-id=\"show-cancer\" data-orig_data_id=\"show-cancer\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Ann\u00e9e : <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-cancer-year-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-cancer-year-fr\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Traitements : (Chemotherapy\/Radiotherapy)\u00a0?<span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-cancer-treatments-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-cancer-treatments-fr\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Avez-vous d\u00e9j\u00e0 subi une greffe ?<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-transplant-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-transplant-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-transplant-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div data-id=\"show-transplant\" data-orig_data_id=\"show-transplant\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Ann\u00e9e <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-transplant-year-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-transplant-year-fr\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Localisation <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-transplant-location-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-transplant-location-fr\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Avez-vous une ou des proth\u00e8ses articulaires ? (Hanche, genou)\u00a0<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-prostheses-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-prostheses-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-prostheses-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div data-id=\"show-prostheses\" data-orig_data_id=\"show-prostheses\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Depuis combien d\u2019ann\u00e9es <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-protheses-year-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-protheses-year-fr\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Suivez-vous une di\u00e8te sp\u00e9ciale ?<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-special-diet-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-special-diet-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-special-diet-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>\u00cates-vous atteint du syndrome d\u2019immunod\u00e9ficience acquise ?<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-immune-deficiency-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-immune-deficiency-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-immune-deficiency-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Avez-vous des maux de t\u00eate fr\u00e9quents, migraines, Maux d\u2019oreilles ?<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-migraines-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-migraines-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-migraines-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Perte de conscience, vertiges\u00a0<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-consciousness-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-consciousness-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-consciousness-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Ronflement ou Apn\u00e9e du sommeil<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-apnea-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-apnea-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-apnea-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div data-id=\"show-apnea\" data-orig_data_id=\"show-apnea\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Avez-vous un CPAP ?\u00a0<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-cpap-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-cpap-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-cpap-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Perte ou Gain de poids anormale, Anorexie, difficult\u00e9 \u00e0 avaler<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-abnormal-weight-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-abnormal-weight-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-abnormal-weight-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Fatigue ou Stress important<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-fatigue-stress-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-fatigue-stress-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-fatigue-stress-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Probl\u00e8me de peau (Psoriasis, Ecz\u00e9ma, Autre)<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-skin-problem-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-skin-problem-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-skin-problem-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Rhume des foins \/ Allergies saisonni\u00e8res<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-hay-fever-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-hay-fever-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-hay-fever-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Souffrez-vous de s\u00e9cheresse de la bouche ?<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-dry-mouth-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-dry-mouth-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-dry-mouth-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Prenez-vous ou avez-vous d\u00e9j\u00e0 eu recours \u00e0 la prise de bisphosphates pour traiter<br \/>\nune maladie ?<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-bisphosphates-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-bisphosphates-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-bisphosphates-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Prenez-vous des m\u00e9dicaments, produits naturels ou hom\u00e9opathiques ?<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-homeopathic-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-homeopathic-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-homeopathic-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div data-id=\"show-homeopathic\" data-orig_data_id=\"show-homeopathic\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Informations sur les m\u00e9dicaments, produits naturels ou hom\u00e9opathiques<\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Nom du m\u00e9dicament <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-drug-1-name-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-drug-1-name-fr\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Mg\/jour <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-drug-1-quantity-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-drug-1-quantity-fr\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Maladie trait\u00e9e<span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-drug-1-disease-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-drug-1-disease-fr\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Nom du m\u00e9dicament <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-drug-2-name-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-drug-2-name-fr\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Mg\/jour <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-drug-2-quantity-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-drug-2-quantity-fr\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Maladie trait\u00e9e<span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-drug-2-disease-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-drug-2-disease-fr\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Nom du m\u00e9dicament <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-drug-3-name-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-drug-3-name-fr\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Mg\/jour<span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-drug-3-quantity-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-drug-3-quantity-fr\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Maladie trait\u00e9e<span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-drug-3-disease-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-drug-3-disease-fr\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Avez-vous d\u00e9j\u00e0 eu une r\u00e9action allergique aux produits suivants :<\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Latex<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-allergy-latex-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-allergy-latex-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-allergy-latex-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Aspirine \/ Ibuprof\u00e8ne \/ Ac\u00e9taminoph\u00e8ne<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-allergy-aspirin-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-allergy-aspirin-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-allergy-aspirin-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>P\u00e9nicilline<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-allergy-penicillin-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-allergy-penicillin-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-allergy-penicillin-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Sulfamides<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-allergy-sulfonamides-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-allergy-sulfonamides-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-allergy-sulfonamides-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Cod\u00e9ine<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-allergy-codeine-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-allergy-codeine-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-allergy-codeine-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Iode<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-allergy-iodine-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-allergy-iodine-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-allergy-iodine-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Anesth\u00e9sie locale<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-allergy-anesthesia-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-allergy-anesthesia-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-allergy-anesthesia-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Aliments<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-allergy-food-fr\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"mf-history-allergy-food-fr\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"mf-history-allergy-food-fr\" value=\"non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Autres <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-history-allergy-others-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-history-allergy-others-fr\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Je, soussign\u00e9, d\u00e9clare avoir lu, compris, m\u2019\u00eatre renseign\u00e9 et avoir r\u00e9pondu au questionnaire m\u00e9dico-dentaire au meilleur de ma connaissance. Je m\u2019engage par la pr\u00e9sente, \u00e0 vous aviser de tout changement de mon \u00e9tat de sant\u00e9.<br \/>\nInitial du patient: <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-understand-initial-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-understand-initial-fr\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Je m\u2019engage \u00e0 contacter le Centre Dentaire Griffin au moins 48 heures \u00e0 l\u2019avance si l\u2019heure ou la date de mon rendez-vous devait \u00eatre modifi\u00e9. (Ce temps vous est r\u00e9serv\u00e9. Des frais de 60$ pour chaque heure perdu seront appliqu\u00e9s \u00e0 votre solde pour le non-respect du rendez-vous.).<br \/>\nInitial du patient: <span class=\"wpcf7-form-control-wrap\" data-name=\"mf-agree-initial-fr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mf-agree-initial-fr\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Envoyer\" \/>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div><div class=\"fusion-alert alert custom alert-custom fusion-alert-center wpcf7-response-output fusion-alert-capitalize awb-alert-native-link-color alert-dismissable awb-alert-close-boxed\" style=\"--awb-border-size:1px;--awb-border-top-left-radius:0px;--awb-border-top-right-radius:0px;--awb-border-bottom-left-radius:0px;--awb-border-bottom-right-radius:0px;\" role=\"alert\"><div class=\"fusion-alert-content-wrapper\"><span class=\"fusion-alert-content\"><\/span><\/div><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><\/div>\n<\/form>\n<\/div>\n<\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-3 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:26px;--awb-padding-bottom:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1320.8px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-margin-top-large:0px;--awb-spacing-right-large:0%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:5.76%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div ><a class=\"fusion-button button-flat button-xlarge button-custom fusion-button-default button-2 fusion-button-default-span fusion-button-default-type\" style=\"--button_accent_color:#656a70;--button_accent_hover_color:#6b6b6b;--button_border_hover_color:#ffffff;--button_gradient_top_color:rgba(0,0,0,0);--button_gradient_bottom_color:rgba(0,0,0,0);--button_gradient_top_color_hover:rgba(40,45,51,0.1);--button_gradient_bottom_color_hover:rgba(40,45,51,0.1);\" target=\"_self\" href=\"https:\/\/vjwq067yt6d.c.updraftclone.com\/fr\/forms\/\"><i class=\"fa-arrow-left fas awb-button__icon awb-button__icon--default button-icon-left\" aria-hidden=\"true\"><\/i><span class=\"fusion-button-text awb-button__text awb-button__text--default\">RETOURNER AU FORMULAIRES<\/span><\/a><\/div><\/div><\/div><\/div><\/div><\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":3,"featured_media":0,"parent":3786,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-3788","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/vjwq067yt6d.c.updraftclone.com\/fr\/wp-json\/wp\/v2\/pages\/3788","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/vjwq067yt6d.c.updraftclone.com\/fr\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/vjwq067yt6d.c.updraftclone.com\/fr\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/vjwq067yt6d.c.updraftclone.com\/fr\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/vjwq067yt6d.c.updraftclone.com\/fr\/wp-json\/wp\/v2\/comments?post=3788"}],"version-history":[{"count":12,"href":"https:\/\/vjwq067yt6d.c.updraftclone.com\/fr\/wp-json\/wp\/v2\/pages\/3788\/revisions"}],"predecessor-version":[{"id":3963,"href":"https:\/\/vjwq067yt6d.c.updraftclone.com\/fr\/wp-json\/wp\/v2\/pages\/3788\/revisions\/3963"}],"up":[{"embeddable":true,"href":"https:\/\/vjwq067yt6d.c.updraftclone.com\/fr\/wp-json\/wp\/v2\/pages\/3786"}],"wp:attachment":[{"href":"https:\/\/vjwq067yt6d.c.updraftclone.com\/fr\/wp-json\/wp\/v2\/media?parent=3788"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}