{"id":6993,"date":"2026-05-23T13:20:35","date_gmt":"2026-05-23T13:20:35","guid":{"rendered":"https:\/\/talpadent.lu\/medical-and-dental-history\/"},"modified":"2026-05-29T12:44:48","modified_gmt":"2026-05-29T12:44:48","slug":"medical-and-dental-history","status":"publish","type":"page","link":"https:\/\/talpadent.lu\/fr\/medical-and-dental-history\/","title":{"rendered":"ANT\u00c9C\u00c9DENTS M\u00c9DICAUX ET DENTAIRES"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"6993\" class=\"elementor elementor-6993 elementor-6906\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-17450b0 e-flex e-con-boxed e-con e-parent\" data-id=\"17450b0\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-98423cd elementor-widget elementor-widget-heading\" data-id=\"98423cd\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Questionnaire<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-642fd67 e-flex e-con-boxed e-con e-parent\" data-id=\"642fd67\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-91190aa elementor-widget elementor-widget-heading\" data-id=\"91190aa\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">ANT\u00c9C\u00c9DENTS M\u00c9DICAUX ET DENTAIRES <\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-fd3ead0 elementor-widget elementor-widget-formidable\" data-id=\"fd3ead0\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"formidable.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_1_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_questionnaire\" >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Questionnaire<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"1\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_1\" id=\"frm_hide_fields_1\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"questionnaire\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_1\" name=\"frm_submit_entry_1\" value=\"cbab1b324c\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/fr\/wp-json\/wp\/v2\/pages\/6993\" \/><div id=\"frm_field_89_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div  id=\"field_qfeg1_label\" class=\"frm_primary_label\">\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_qfeg1_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_89-0\">\t\t\t<label  for=\"field_qfeg1-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[89]\" id=\"field_qfeg1-0\" value=\"Mrs\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Mme<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_89-1\">\t\t\t<label  for=\"field_qfeg1-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[89]\" id=\"field_qfeg1-1\" value=\"Miss\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Mlle<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_89-2\">\t\t\t<label  for=\"field_qfeg1-2\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[89]\" id=\"field_qfeg1-2\" value=\"Mr\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> M.<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_87_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n\t<label for=\"field_1fe0c\" id=\"field_1fe0c_label\" class=\"frm_primary_label\">Nom de famille\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_1fe0c\" name=\"item_meta[87]\" value=\"\"  placeholder=\"e.g. SMITH\" data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_88_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n\t<label for=\"field_4je2c\" id=\"field_4je2c_label\" class=\"frm_primary_label\">Pr\u00e9nom\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_4je2c\" name=\"item_meta[88]\" value=\"\"  placeholder=\"e.g. John\" data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_8_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\">\r\n\t<label for=\"field_47ajn\" id=\"field_47ajn_label\" class=\"frm_primary_label\">Code postal\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_47ajn\" name=\"item_meta[8]\" value=\"\"  placeholder=\"e.g. L-1234\" data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_9_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\">\r\n\t<label for=\"field_o81u1\" id=\"field_o81u1_label\" class=\"frm_primary_label\">Localit\u00e9\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_o81u1\" name=\"item_meta[9]\" value=\"\"  placeholder=\"e.g. Luxembourg\" data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_10_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n\t<label for=\"field_oz2a2\" id=\"field_oz2a2_label\" class=\"frm_primary_label\">Num\u00e9ro de rue\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_oz2a2\" name=\"item_meta[10]\" value=\"\"  placeholder=\"e.g. 12 Example Street\" data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_11_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n\t<label for=\"field_fr76c\" id=\"field_fr76c_label\" class=\"frm_primary_label\">Profession\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_fr76c\" name=\"item_meta[11]\" value=\"\"  placeholder=\"e.g. Teacher\" data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_12_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n\t<label for=\"field_ydxcj\" id=\"field_ydxcj_label\" class=\"frm_primary_label\">Date de naissance\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_ydxcj\" name=\"item_meta[12]\" value=\"\"  placeholder=\"e.g. 01\/01\/1990\" data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_14_container\" class=\"frm_form_field form-field  frm_top_container frm6\">\r\n\t<label for=\"field_e2907\" id=\"field_e2907_label\" class=\"frm_primary_label\">Num\u00e9ro de s\u00e9curit\u00e9 sociale\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_e2907\" name=\"item_meta[14]\" value=\"\"  placeholder=\"e.g. 1990010100000\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_16_container\" class=\"frm_form_field form-field  frm_top_container frm12 frm6 frm_first\">\r\n\t<label for=\"field_e5dpy\" id=\"field_e5dpy_label\" class=\"frm_primary_label\">Caisse de maladie\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_e5dpy\" name=\"item_meta[16]\" value=\"\"  placeholder=\"e.g. CNS\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_15_container\" class=\"frm_form_field form-field  frm_top_container frm6\">\r\n\t<label for=\"field_ghtzs\" id=\"field_ghtzs_label\" class=\"frm_primary_label\">Assurance compl\u00e9mentaire\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_ghtzs\" name=\"item_meta[15]\" value=\"\"  placeholder=\"e.g. DKV \/ Foyer \/ None\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_17_container\" class=\"frm_form_field form-field  frm_top_container frm4 frm_first\">\r\n\t<label for=\"field_yiwmf\" id=\"field_yiwmf_label\" class=\"frm_primary_label\">GSM\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_yiwmf\" name=\"item_meta[17]\" value=\"\"  placeholder=\"e.g. +352 621 000 000\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_18_container\" class=\"frm_form_field form-field  frm_top_container frm4\">\r\n\t<label for=\"field_kzh37\" id=\"field_kzh37_label\" class=\"frm_primary_label\">T\u00e9l\u00e9phone r\u00e9sidentiel\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"tel\" id=\"field_kzh37\" name=\"item_meta[18]\" value=\"\"  placeholder=\"e.g. +352 26 00 00\" data-invmsg=\"[nom_du_champ] est invalide\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_19_container\" class=\"frm_form_field form-field  frm_top_container frm4\">\r\n\t<label for=\"field_4cxnh\" id=\"field_4cxnh_label\" class=\"frm_primary_label\">T\u00e9l\u00e9phone de bureau\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"tel\" id=\"field_4cxnh\" name=\"item_meta[19]\" value=\"\"  placeholder=\"e.g. +352 27 00 00\" data-invmsg=\"[nom_du_champ] est invalide\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_3_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n\t<label for=\"field_29yf4d\" id=\"field_29yf4d_label\" class=\"frm_primary_label\">Adresse email\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"email\" id=\"field_29yf4d\" name=\"item_meta[3]\" value=\"\"  placeholder=\"e.g. john.smith@email.com\" data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"S&#039;il vous pla\u00eet, mettez une adresse email valide\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_4_container\" class=\"frm_form_field form-field  frm_top_container frm_full\">\r\n\t<label for=\"field_e6lis6\" id=\"field_e6lis6_label\" class=\"frm_primary_label\">Comment avez-vous trouv\u00e9 le cabinet?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_e6lis6\" name=\"item_meta[4]\" value=\"\"  placeholder=\"e.g. Doctena \/ Google \/ Friend\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_20_container\" class=\"frm_form_field  frm_html_container form-field\">\n<h3>ANT\u00c9C\u00c9DENTS M\u00c9DICAUX<\/h3>\n<\/div>\n<div id=\"frm_field_5_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_first\">\r\n\t<label for=\"field_9jv0r1\" id=\"field_9jv0r1_label\" class=\"frm_primary_label\">Le nom, l'adresse et le num\u00e9ro de t\u00e9l\u00e9phone de votre m\u00e9decin\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<textarea name=\"item_meta[5]\" id=\"field_9jv0r1\" rows=\"4\"  placeholder=\"e.g. Dr Example, 1 Health Street, L-1234 Luxembourg, +352 26 00 00\r\ne.g. General practitioner \/ specialist if applicable\" data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-invalid=\"false\"  ><\/textarea>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_21_container\" class=\"frm_form_field form-field  frm_top_container frm12 frm_first\">\r\n\t<label for=\"field_gvfbp\" id=\"field_gvfbp_label\" class=\"frm_primary_label\">Quand avez-vous pass\u00e9 votre dernier examen m\u00e9dical ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_gvfbp\" name=\"item_meta[21]\" value=\"\"  placeholder=\"e.g. 2025 \/ less than 1 year ago\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_22_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_first horizontal_radio\">\r\n\t<div  id=\"field_ujiy6_label\" class=\"frm_primary_label\">Avez-vous constat\u00e9 des changements dans votre sant\u00e9 au cours de la derni\u00e8re ann\u00e9e ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_ujiy6_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_22-0\">\t\t\t<label  for=\"field_ujiy6-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[22]\" id=\"field_ujiy6-0\" value=\"Yes\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_22-1\">\t\t\t<label  for=\"field_ujiy6-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[22]\" id=\"field_ujiy6-1\" value=\"No\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Non<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_23_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_three_col\">\r\n\t<div  id=\"field_9zzx7_label\" class=\"frm_primary_label\">Veuillez cocher chacune des maladies ou probl\u00e8mes suivants que vous avez pu avoir par le pass\u00e9 ou que vous avez actuellement.\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_9zzx7_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-0\">\t\t\t<label  for=\"field_9zzx7-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_9zzx7-0\" value=\"Depression\"  data-frmlimit=\"27\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   aria-required=\"true\"  \/> D\u00e9pression<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-1\">\t\t\t<label  for=\"field_9zzx7-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_9zzx7-1\" value=\"Liver Disease\"  data-frmlimit=\"27\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Maladie du foie<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-2\">\t\t\t<label  for=\"field_9zzx7-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_9zzx7-2\" value=\"Prostheses(Other Than Dental)\"  data-frmlimit=\"27\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Proth\u00e8ses (autres que dentaires)<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-3\">\t\t\t<label  for=\"field_9zzx7-3\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_9zzx7-3\" value=\"Asthma\"  data-frmlimit=\"27\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Asthme<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-4\">\t\t\t<label  for=\"field_9zzx7-4\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_9zzx7-4\" value=\"Heart Disease\"  data-frmlimit=\"27\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Maladie cardiaque<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-5\">\t\t\t<label  for=\"field_9zzx7-5\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_9zzx7-5\" value=\"Acute Articular Rhumatism\"  data-frmlimit=\"27\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Rhumatisme articulaire aigu<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-6\">\t\t\t<label  for=\"field_9zzx7-6\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_9zzx7-6\" value=\"Plastic Surgery\"  data-frmlimit=\"27\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Chirurgie plastique<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-7\">\t\t\t<label  for=\"field_9zzx7-7\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_9zzx7-7\" value=\"Blood Disease\"  data-frmlimit=\"27\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Maladie du sang<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-8\">\t\t\t<label  for=\"field_9zzx7-8\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_9zzx7-8\" value=\"HIV Positive\"  data-frmlimit=\"27\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> VIH positif<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-9\">\t\t\t<label  for=\"field_9zzx7-9\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_9zzx7-9\" value=\"Hormonal Disorders\"  data-frmlimit=\"27\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Troubles hormonaux<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-10\">\t\t\t<label  for=\"field_9zzx7-10\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_9zzx7-10\" value=\"Venereal Diseases\"  data-frmlimit=\"27\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Maladies v\u00e9n\u00e9riennes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-11\">\t\t\t<label  for=\"field_9zzx7-11\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_9zzx7-11\" value=\"Repeated Sinusitis\"  data-frmlimit=\"27\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Sinusite r\u00e9currente<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-12\">\t\t\t<label  for=\"field_9zzx7-12\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_9zzx7-12\" value=\"Diabetes\"  data-frmlimit=\"27\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> D\u00e9pression<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-13\">\t\t\t<label  for=\"field_9zzx7-13\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_9zzx7-13\" value=\"Edema (Swelling)\"  data-frmlimit=\"27\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> \u0152d\u00e8me (gonflement)<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-14\">\t\t\t<label  for=\"field_9zzx7-14\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_9zzx7-14\" value=\"Syncope,Dizziness\"  data-frmlimit=\"27\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Syncope, vertiges<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-15\">\t\t\t<label  for=\"field_9zzx7-15\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_9zzx7-15\" value=\"Glaucoma\"  data-frmlimit=\"27\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Glaucome<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-16\">\t\t\t<label  for=\"field_9zzx7-16\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_9zzx7-16\" value=\"Pacemaker\"  data-frmlimit=\"27\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Stimulateur cardiaque<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-17\">\t\t\t<label  for=\"field_9zzx7-17\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_9zzx7-17\" value=\"Thyroid\"  data-frmlimit=\"27\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Thyro\u00efde<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-18\">\t\t\t<label  for=\"field_9zzx7-18\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_9zzx7-18\" value=\"Hepatitis A, B or C\"  data-frmlimit=\"27\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> H\u00e9patite A, B ou C<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-19\">\t\t\t<label  for=\"field_9zzx7-19\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_9zzx7-19\" value=\"Loss of consciousness\"  data-frmlimit=\"27\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Perte de conscience<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-20\">\t\t\t<label  for=\"field_9zzx7-20\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_9zzx7-20\" value=\"Kidney Problems\"  data-frmlimit=\"27\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Probl\u00e8mes r\u00e9naux<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-21\">\t\t\t<label  for=\"field_9zzx7-21\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_9zzx7-21\" value=\"Congenital Heart Damage\"  data-frmlimit=\"27\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> L\u00e9sions cardiaques cong\u00e9nitales<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-22\">\t\t\t<label  for=\"field_9zzx7-22\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_9zzx7-22\" value=\"Circulatory Problems\"  data-frmlimit=\"27\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Probl\u00e8mes circulatoires<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-23\">\t\t\t<label  for=\"field_9zzx7-23\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_9zzx7-23\" value=\"Malignant Tumor\"  data-frmlimit=\"27\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Tumeur maligne<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-24\">\t\t\t<label  for=\"field_9zzx7-24\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_9zzx7-24\" value=\"Stomach Ulcers\"  data-frmlimit=\"27\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Ulc\u00e8res d'estomac<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-25\">\t\t\t<label  for=\"field_9zzx7-25\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_9zzx7-25\" value=\"Nervous Problems\"  data-frmlimit=\"27\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Probl\u00e8mes nerveux<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-26\">\t\t\t<label  for=\"field_9zzx7-26\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_9zzx7-26\" value=\"None\"  data-frmlimit=\"27\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Aucun<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_24_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div  id=\"field_ii0t4_label\" class=\"frm_primary_label\">Avez-vous d\u00e9j\u00e0 eu des saignements anormaux lors d\u2019une op\u00e9ration ou d\u2019un accident ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_ii0t4_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_24-0\">\t\t\t<label  for=\"field_ii0t4-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[24]\" id=\"field_ii0t4-0\" value=\"Yes\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_24-1\">\t\t\t<label  for=\"field_ii0t4-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[24]\" id=\"field_ii0t4-1\" value=\"No\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Non<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_25_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div  id=\"field_ndk1z_label\" class=\"frm_primary_label\">Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 trait\u00e9 par radioth\u00e9rapie ou chimioth\u00e9rapie ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_ndk1z_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_25-0\">\t\t\t<label  for=\"field_ndk1z-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[25]\" id=\"field_ndk1z-0\" value=\"Yes\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_25-1\">\t\t\t<label  for=\"field_ndk1z-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[25]\" id=\"field_ndk1z-1\" value=\"No\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Non<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_26_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div  id=\"field_mq9uv_label\" class=\"frm_primary_label\">Prenez-vous actuellement des m\u00e9dicaments?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_mq9uv_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_26-0\">\t\t\t<label  for=\"field_mq9uv-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[26]\" id=\"field_mq9uv-0\" value=\"Yes\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_26-1\">\t\t\t<label  for=\"field_mq9uv-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[26]\" id=\"field_mq9uv-1\" value=\"No\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Non<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_28_container\" class=\"frm_form_field form-field  frm_required_field frm_left_container frm_three_col\">\r\n\t<div  id=\"field_5qyr4_label\" class=\"frm_primary_label\">Lesquels\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_5qyr4_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_28-0\">\t\t\t<label  for=\"field_5qyr4-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[28][]\" id=\"field_5qyr4-0\" value=\"Antibiotics\"  data-frmlimit=\"12\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   aria-required=\"true\" aria-describedby=\"frm_desc_field_5qyr4\"  \/> Antibiotiques<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_28-1\">\t\t\t<label  for=\"field_5qyr4-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[28][]\" id=\"field_5qyr4-1\" value=\"Aspirin\"  data-frmlimit=\"12\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-describedby=\"frm_desc_field_5qyr4\"   \/> Aspirine<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_28-2\">\t\t\t<label  for=\"field_5qyr4-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[28][]\" id=\"field_5qyr4-2\" value=\"Antihistamine\"  data-frmlimit=\"12\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-describedby=\"frm_desc_field_5qyr4\"   \/> Antihistamine<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_28-3\">\t\t\t<label  for=\"field_5qyr4-3\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[28][]\" id=\"field_5qyr4-3\" value=\"Treatment for Blood Pressure\"  data-frmlimit=\"12\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-describedby=\"frm_desc_field_5qyr4\"   \/> Traitement de la tension art\u00e9rielle<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_28-4\">\t\t\t<label  for=\"field_5qyr4-4\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[28][]\" id=\"field_5qyr4-4\" value=\"Tranquilizer\"  data-frmlimit=\"12\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-describedby=\"frm_desc_field_5qyr4\"   \/> Tranquillisant<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_28-5\">\t\t\t<label  for=\"field_5qyr4-5\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[28][]\" id=\"field_5qyr4-5\" value=\"Cortisone\"  data-frmlimit=\"12\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-describedby=\"frm_desc_field_5qyr4\"   \/> Cortisone<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_28-6\">\t\t\t<label  for=\"field_5qyr4-6\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[28][]\" id=\"field_5qyr4-6\" value=\"Insulin\"  data-frmlimit=\"12\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-describedby=\"frm_desc_field_5qyr4\"   \/> Insuline<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_28-7\">\t\t\t<label  for=\"field_5qyr4-7\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[28][]\" id=\"field_5qyr4-7\" value=\"Biphosphonate\"  data-frmlimit=\"12\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-describedby=\"frm_desc_field_5qyr4\"   \/> Biphosphonate<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_28-8\">\t\t\t<label  for=\"field_5qyr4-8\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[28][]\" id=\"field_5qyr4-8\" value=\"Di-Hydan (Anti-Epileptic)\"  data-frmlimit=\"12\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-describedby=\"frm_desc_field_5qyr4\"   \/> Di-Hydan (anti\u00e9pileptique)<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_28-9\">\t\t\t<label  for=\"field_5qyr4-9\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[28][]\" id=\"field_5qyr4-9\" value=\"Anticoagulant\"  data-frmlimit=\"12\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-describedby=\"frm_desc_field_5qyr4\"   \/> Anticoagulant<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_28-10\">\t\t\t<label  for=\"field_5qyr4-10\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[28][]\" id=\"field_5qyr4-10\" value=\"Other\"  data-frmlimit=\"12\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-describedby=\"frm_desc_field_5qyr4\"   \/> Autre<\/label><\/div>\n<\/div>\r\n\t<div class=\"frm_description\" id=\"frm_desc_field_5qyr4\">e.g. medication name + dosage + frequency<\/div>\r\n\t\r\n<\/div>\n<div id=\"frm_field_114_container\" class=\"frm_form_field form-field  frm_top_container\">\n\t<label for=\"field_byhrb\" id=\"field_byhrb_label\" class=\"frm_primary_label\">Autres m\u00e9dicaments\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t<input  type=\"text\" id=\"field_byhrb\" name=\"item_meta[114]\" value=\"\"  data-invmsg=\"[nom_du_champ] ass ong\u00eblteg\" aria-invalid=\"false\"   \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_29_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div  id=\"field_8dlx0_label\" class=\"frm_primary_label\">Etes-vous allergique \u00e0 certains produits ou m\u00e9dicaments ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_8dlx0_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_29-0\">\t\t\t<label  for=\"field_8dlx0-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[29]\" id=\"field_8dlx0-0\" value=\"Yes\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_29-1\">\t\t\t<label  for=\"field_8dlx0-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[29]\" id=\"field_8dlx0-1\" value=\"No\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Non<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_30_container\" class=\"frm_form_field form-field  frm_required_field frm_left_container frm_three_col\">\r\n\t<div  id=\"field_6zw98_label\" class=\"frm_primary_label\">Lesquels\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_6zw98_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_30-0\">\t\t\t<label  for=\"field_6zw98-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[30][]\" id=\"field_6zw98-0\" value=\"Dentist\u2019s Local Anesthesic\"  data-frmlimit=\"15\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   aria-required=\"true\" aria-describedby=\"frm_desc_field_6zw98\"  \/> Anesth\u00e9sique local du dentiste<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_30-1\">\t\t\t<label  for=\"field_6zw98-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[30][]\" id=\"field_6zw98-1\" value=\"Iodine and Derivatives\"  data-frmlimit=\"15\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-describedby=\"frm_desc_field_6zw98\"   \/> Iode et d\u00e9riv\u00e9s<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_30-2\">\t\t\t<label  for=\"field_6zw98-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[30][]\" id=\"field_6zw98-2\" value=\"Metal\"  data-frmlimit=\"15\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-describedby=\"frm_desc_field_6zw98\"   \/> M\u00e9tal<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_30-3\">\t\t\t<label  for=\"field_6zw98-3\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[30][]\" id=\"field_6zw98-3\" value=\"Antibiotic\"  data-frmlimit=\"15\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-describedby=\"frm_desc_field_6zw98\"   \/> Antibiotique<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_30-4\">\t\t\t<label  for=\"field_6zw98-4\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[30][]\" id=\"field_6zw98-4\" value=\"Latex\"  data-frmlimit=\"15\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-describedby=\"frm_desc_field_6zw98\"   \/> Latex<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_30-5\">\t\t\t<label  for=\"field_6zw98-5\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[30][]\" id=\"field_6zw98-5\" value=\"Barbituriques\"  data-frmlimit=\"15\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-describedby=\"frm_desc_field_6zw98\"   \/> Barbituriques<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_30-6\">\t\t\t<label  for=\"field_6zw98-6\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[30][]\" id=\"field_6zw98-6\" value=\"Anti-inflammatory or Aspirin\"  data-frmlimit=\"15\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-describedby=\"frm_desc_field_6zw98\"   \/> Anti-inflammatoire ou Aspirine<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_30-7\">\t\t\t<label  for=\"field_6zw98-7\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[30][]\" id=\"field_6zw98-7\" value=\"Penicillin\"  data-frmlimit=\"15\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-describedby=\"frm_desc_field_6zw98\"   \/> P\u00e9nicilline<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_30-8\">\t\t\t<label  for=\"field_6zw98-8\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[30][]\" id=\"field_6zw98-8\" value=\"Neuroleptic or Sleeping Pill\"  data-frmlimit=\"15\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-describedby=\"frm_desc_field_6zw98\"   \/> Neuroleptique ou somnif\u00e8re<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_30-9\">\t\t\t<label  for=\"field_6zw98-9\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[30][]\" id=\"field_6zw98-9\" value=\"Codeine\"  data-frmlimit=\"15\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-describedby=\"frm_desc_field_6zw98\"   \/> Cod\u00e9ine<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_30-10\">\t\t\t<label  for=\"field_6zw98-10\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[30][]\" id=\"field_6zw98-10\" value=\"Other\"  data-frmlimit=\"15\"  data-frmmin=\"1\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-describedby=\"frm_desc_field_6zw98\"   \/> Autre<\/label><\/div>\n<\/div>\r\n\t<div class=\"frm_description\" id=\"frm_desc_field_6zw98\">e.g. penicillin, latex, iodine, none<\/div>\r\n\t\r\n<\/div>\n<div id=\"frm_field_115_container\" class=\"frm_form_field form-field  frm_top_container\">\n\t<label for=\"field_izyfy\" id=\"field_izyfy_label\" class=\"frm_primary_label\">Autres produits ou m\u00e9dicaments\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t<input  type=\"text\" id=\"field_izyfy\" name=\"item_meta[115]\" value=\"\"  data-invmsg=\"[nom_du_champ] est invalide\" aria-invalid=\"false\"   \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_33_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first horizontal_radio\">\r\n\t<div  id=\"field_kpwmb_label\" class=\"frm_primary_label\">Fumez-vous?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_kpwmb_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_33-0\">\t\t\t<label  for=\"field_kpwmb-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[33]\" id=\"field_kpwmb-0\" value=\"Yes\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_33-1\">\t\t\t<label  for=\"field_kpwmb-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[33]\" id=\"field_kpwmb-1\" value=\"No\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Non<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_32_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n\t<label for=\"field_hiuys\" id=\"field_hiuys_label\" class=\"frm_primary_label\">Nombre de cigarettes\/jour et pendant combien de temps\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_hiuys\" name=\"item_meta[32]\" value=\"\"  placeholder=\"e.g. 5 cigarettes\/day for 10 years\" data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"Nombre de cigarettes\/jour et pendant combien de temps n&#039;est pas valide\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_31_container\" class=\"frm_form_field form-field  frm_top_container frm12 frm_first horizontal_radio\">\r\n\t<div  id=\"field_epcls_label\" class=\"frm_primary_label\">Madame, Mademoiselle, \u00eates-vous enceinte ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_epcls_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_31-0\">\t\t\t<label  for=\"field_epcls-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[31]\" id=\"field_epcls-0\" value=\"Yes\"\n\t\t data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_31-1\">\t\t\t<label  for=\"field_epcls-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[31]\" id=\"field_epcls-1\" value=\"No\"\n\t\t data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Non<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_34_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_55n61\" id=\"field_55n61_label\" class=\"frm_primary_label\">Combien de mois\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_55n61\" name=\"item_meta[34]\" value=\"\"  placeholder=\"e.g. 4 months\" data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_36_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_first horizontal_radio\">\r\n\t<div  id=\"field_apcag_label\" class=\"frm_primary_label\">Prenez-vous actuellement la pilule ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_apcag_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_36-0\">\t\t\t<label  for=\"field_apcag-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[36]\" id=\"field_apcag-0\" value=\"Yes\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_36-1\">\t\t\t<label  for=\"field_apcag-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[36]\" id=\"field_apcag-1\" value=\"No\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Non<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_35_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_3a0wy\" id=\"field_3a0wy_label\" class=\"frm_primary_label\">Combien de mois\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_3a0wy\" name=\"item_meta[35]\" value=\"\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_38_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_first horizontal_radio\">\r\n\t<div  id=\"field_bkvqb_label\" class=\"frm_primary_label\">\u00cates-vous sous traitement pour l\u2019ost\u00e9oporose ou une autre maladie osseuse ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_bkvqb_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_38-0\">\t\t\t<label  for=\"field_bkvqb-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[38]\" id=\"field_bkvqb-0\" value=\"Yes\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_38-1\">\t\t\t<label  for=\"field_bkvqb-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[38]\" id=\"field_bkvqb-1\" value=\"No\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Non<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_39_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_first horizontal_radio\">\r\n\t<div  id=\"field_xn548_label\" class=\"frm_primary_label\">Quel type de m\u00e9dicaments prenez-vous ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_xn548_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_39-0\">\t\t\t<label  for=\"field_xn548-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[39][]\" id=\"field_xn548-0\" value=\"Hormones\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   aria-required=\"true\"  \/> Hormones<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_39-1\">\t\t\t<label  for=\"field_xn548-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[39][]\" id=\"field_xn548-1\" value=\"Estrogens\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> \u0152strog\u00e8nes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_39-2\">\t\t\t<label  for=\"field_xn548-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[39][]\" id=\"field_xn548-2\" value=\"Biphosphonates\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Biphosphonates<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_39-3\">\t\t\t<label  for=\"field_xn548-3\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[39][]\" id=\"field_xn548-3\" value=\"Other\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Autres m\u00e9dicaments<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_116_container\" class=\"frm_form_field form-field  frm_top_container\">\n\t<label for=\"field_cq7vc\" id=\"field_cq7vc_label\" class=\"frm_primary_label\">Autres m\u00e9dicaments\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t<input  type=\"text\" id=\"field_cq7vc\" name=\"item_meta[116]\" value=\"\"  data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-invalid=\"false\"   \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_40_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_werjp\" id=\"field_werjp_label\" class=\"frm_primary_label\">Si vous pensez avoir une autre maladie ou tout autre probl\u00e8me non indiqu\u00e9 dans la liste ci-dessus et qui pourrait nous aider \u00e0 vous traiter dans les meilleures conditions, merci de le pr\u00e9ciser ici\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<textarea name=\"item_meta[40]\" id=\"field_werjp\" rows=\"5\"  placeholder=\"e.g. High blood pressure controlled by medication \/ asthma \/ surgery \/ none known e.g. Any important information not listed above that may affect dental treatment\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-invalid=\"false\"  ><\/textarea>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_41_container\" class=\"frm_form_field  frm_html_container form-field\">\n<h3>HISTOIRE DENTAIRE<\/h3>\n<\/div>\n<div id=\"frm_field_42_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_4q25g\" id=\"field_4q25g_label\" class=\"frm_primary_label\">\u00c0 quand remonte votre dernier examen dentaire\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_4q25g\" name=\"item_meta[42]\" value=\"\"  placeholder=\"e.g. 6 months ago \/ 2025\" data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_43_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_7u79t\" id=\"field_7u79t_label\" class=\"frm_primary_label\">Quel est le motif de votre consultation ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_7u79t\" name=\"item_meta[43]\" value=\"\"  placeholder=\"e.g. check-up \/ pain \/ cleaning \/ aesthetic concern\" data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_44_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_z02bg\" id=\"field_z02bg_label\" class=\"frm_primary_label\">Lors de vos pr\u00e9c\u00e9dentes visites chez le dentiste, avez-vous rencontr\u00e9 des difficult\u00e9s particuli\u00e8res ? Si oui, lequel ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_z02bg\" name=\"item_meta[44]\" value=\"\"  placeholder=\"e.g. anxiety, anesthesia difficulty, bleeding, none\" data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_45_container\" class=\"frm_form_field  frm_html_container form-field\">\n<h5><strong>HYGI\u00c8NE DENTAIRE<\/strong><\/h5>\n<\/div>\n<div id=\"frm_field_46_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div  id=\"field_oynlr_label\" class=\"frm_primary_label\">Utilisez-vous une brosse \u00e0 dents\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_oynlr_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_46-0\">\t\t\t<label  for=\"field_oynlr-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[46][]\" id=\"field_oynlr-0\" value=\"Electric\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   aria-required=\"true\"  \/> \u00c9lectrique<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_46-1\">\t\t\t<label  for=\"field_oynlr-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[46][]\" id=\"field_oynlr-1\" value=\"Manual\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Manuel<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_46-2\">\t\t\t<label  for=\"field_oynlr-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[46][]\" id=\"field_oynlr-2\" value=\"Hard\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Dure<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_46-3\">\t\t\t<label  for=\"field_oynlr-3\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[46][]\" id=\"field_oynlr-3\" value=\"Medium\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Moyen<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_46-4\">\t\t\t<label  for=\"field_oynlr-4\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[46][]\" id=\"field_oynlr-4\" value=\"Soft\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Douce<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_47_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div  id=\"field_1tdq3_label\" class=\"frm_primary_label\">Quand te brosses-tu les dents ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_1tdq3_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_47-0\">\t\t\t<label  for=\"field_1tdq3-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[47][]\" id=\"field_1tdq3-0\" value=\"Morning\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   aria-required=\"true\"  \/> Matin<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_47-1\">\t\t\t<label  for=\"field_1tdq3-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[47][]\" id=\"field_1tdq3-1\" value=\"Afternoon\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Apr\u00e8s-midi<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_47-2\">\t\t\t<label  for=\"field_1tdq3-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[47][]\" id=\"field_1tdq3-2\" value=\"Evening\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Soir\u00e9e<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_48_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_dsuba\" id=\"field_dsuba_label\" class=\"frm_primary_label\">\u00c0 quelle fr\u00e9quence changez-vous de brosse \u00e0 dents ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_dsuba\" name=\"item_meta[48]\" value=\"\"  placeholder=\"e.g. every 3 months\" data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_49_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div  id=\"field_c9nu_label\" class=\"frm_primary_label\">Utilisez-vous\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_c9nu_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_49-0\">\t\t\t<label  for=\"field_c9nu-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[49]\" id=\"field_c9nu-0\" value=\"Dental Floss\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Fil dentaire<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_49-1\">\t\t\t<label  for=\"field_c9nu-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[49]\" id=\"field_c9nu-1\" value=\"Interdental Brushes\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Brossettes interdentaires<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_50_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div  id=\"field_isspd_label\" class=\"frm_primary_label\">Avez-vous l'impression d'avoir une mauvaise haleine\/un mauvais go\u00fbt dans la bouche ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_isspd_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_50-0\">\t\t\t<label  for=\"field_isspd-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[50]\" id=\"field_isspd-0\" value=\"Yes\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_50-1\">\t\t\t<label  for=\"field_isspd-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[50]\" id=\"field_isspd-1\" value=\"No\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Non<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_52_container\" class=\"frm_form_field  frm_html_container form-field\">\n<h5>GENCIVES<\/h5>\n<\/div>\n<div id=\"frm_field_51_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div  id=\"field_mt3uc_label\" class=\"frm_primary_label\">Avez-vous remarqu\u00e9 que vos dents se sont s\u00e9par\u00e9es apr\u00e8s un certain temps ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_mt3uc_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_51-0\">\t\t\t<label  for=\"field_mt3uc-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[51]\" id=\"field_mt3uc-0\" value=\"Yes\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_51-1\">\t\t\t<label  for=\"field_mt3uc-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[51]\" id=\"field_mt3uc-1\" value=\"No\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Non<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_53_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div  id=\"field_7l487_label\" class=\"frm_primary_label\">Vos gencives saignent-elles apr\u00e8s le brossage des dents, voire spontan\u00e9ment ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_7l487_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_53-0\">\t\t\t<label  for=\"field_7l487-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[53]\" id=\"field_7l487-0\" value=\"Yes\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_53-1\">\t\t\t<label  for=\"field_7l487-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[53]\" id=\"field_7l487-1\" value=\"No\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Non<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_54_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div  id=\"field_39wvv_label\" class=\"frm_primary_label\">Avez-vous d\u00e9j\u00e0 soign\u00e9 vos gencives ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_39wvv_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_54-0\">\t\t\t<label  for=\"field_39wvv-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[54]\" id=\"field_39wvv-0\" value=\"Yes\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_54-1\">\t\t\t<label  for=\"field_39wvv-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[54]\" id=\"field_39wvv-1\" value=\"No\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Non<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_55_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div  id=\"field_k9pa2_label\" class=\"frm_primary_label\">Par\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_k9pa2_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_55-0\">\t\t\t<label  for=\"field_k9pa2-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[55][]\" id=\"field_k9pa2-0\" value=\"Surgery\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   aria-required=\"true\"  \/> Chirurgie<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_55-1\">\t\t\t<label  for=\"field_k9pa2-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[55][]\" id=\"field_k9pa2-1\" value=\"Medicines\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Medicines<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_55-2\">\t\t\t<label  for=\"field_k9pa2-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[55][]\" id=\"field_k9pa2-2\" value=\"Descaling\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> D\u00e9tartrage<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_56_container\" class=\"frm_form_field  frm_html_container form-field\">\n<h5>DENTS<\/h5>\n<\/div>\n<div id=\"frm_field_58_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div  id=\"field_i5i5d_label\" class=\"frm_primary_label\">Avez-vous d\u00e9j\u00e0 extrait des dents ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_i5i5d_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_58-0\">\t\t\t<label  for=\"field_i5i5d-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[58]\" id=\"field_i5i5d-0\" value=\"Yes\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_58-1\">\t\t\t<label  for=\"field_i5i5d-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[58]\" id=\"field_i5i5d-1\" value=\"No\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Non<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_59_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div  id=\"field_8r99_label\" class=\"frm_primary_label\">Si oui, pourquoi\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_8r99_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_59-0\">\t\t\t<label  for=\"field_8r99-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[59][]\" id=\"field_8r99-0\" value=\"Caries\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   aria-required=\"true\"  \/> Carie<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_59-1\">\t\t\t<label  for=\"field_8r99-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[59][]\" id=\"field_8r99-1\" value=\"Infection or Abscess\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Infection ou abc\u00e8s<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_59-2\">\t\t\t<label  for=\"field_8r99-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[59][]\" id=\"field_8r99-2\" value=\"Receding Gums\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> D\u00e9garnissement des gencives<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_59-3\">\t\t\t<label  for=\"field_8r99-3\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[59][]\" id=\"field_8r99-3\" value=\"Wisdom Tooth\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Dent de sagesse<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_59-4\">\t\t\t<label  for=\"field_8r99-4\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[59][]\" id=\"field_8r99-4\" value=\"Fracture\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Fracture<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_61_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div  id=\"field_bbsc_label\" class=\"frm_primary_label\">Les dents extraites ont-elles \u00e9t\u00e9 remplac\u00e9es ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_bbsc_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_61-0\">\t\t\t<label  for=\"field_bbsc-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[61]\" id=\"field_bbsc-0\" value=\"Yes\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_61-1\">\t\t\t<label  for=\"field_bbsc-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[61]\" id=\"field_bbsc-1\" value=\"No\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Non<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_60_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div  id=\"field_xhryl_label\" class=\"frm_primary_label\">Si oui, par\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_xhryl_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_60-0\">\t\t\t<label  for=\"field_xhryl-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[60][]\" id=\"field_xhryl-0\" value=\"A Fixed Bridge\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   aria-required=\"true\"  \/> Un pont fixe<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_60-1\">\t\t\t<label  for=\"field_xhryl-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[60][]\" id=\"field_xhryl-1\" value=\"Denture\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Dentier<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_60-2\">\t\t\t<label  for=\"field_xhryl-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[60][]\" id=\"field_xhryl-2\" value=\"An Implant\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Un implant<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_62_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_e7cdm\" id=\"field_e7cdm_label\" class=\"frm_primary_label\">Si non, pour quelle raison ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_e7cdm\" name=\"item_meta[62]\" value=\"\"  placeholder=\"e.g. not yet \/ planned implant \/ no discomfort\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_63_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_71thp\" id=\"field_71thp_label\" class=\"frm_primary_label\">Comment vous sentez-vous avec vos proth\u00e8ses actuelles ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_71thp\" name=\"item_meta[63]\" value=\"\"  placeholder=\"e.g. comfortable \/ discomfort while chewing\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_64_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div  id=\"field_mqq80_label\" class=\"frm_primary_label\">Concernant l\u2019utilisation des m\u00e9taux dans votre bouche, avez-vous des pr\u00e9f\u00e9rences particuli\u00e8res ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_mqq80_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_64-0\">\t\t\t<label  for=\"field_mqq80-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[64]\" id=\"field_mqq80-0\" value=\"Yes\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_64-1\">\t\t\t<label  for=\"field_mqq80-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[64]\" id=\"field_mqq80-1\" value=\"No\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Non<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_65_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_r6lj1\" id=\"field_r6lj1_label\" class=\"frm_primary_label\">Si oui, lequel\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_r6lj1\" name=\"item_meta[65]\" value=\"\"  placeholder=\"e.g. metal-free restorations if possible\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_66_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div  id=\"field_i2htb_label\" class=\"frm_primary_label\">Avez-vous des dents sensibles\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_i2htb_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_66-0\">\t\t\t<label  for=\"field_i2htb-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[66][]\" id=\"field_i2htb-0\" value=\"Warm\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   aria-required=\"true\"  \/> Chaude<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_66-1\">\t\t\t<label  for=\"field_i2htb-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[66][]\" id=\"field_i2htb-1\" value=\"Cold\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Froide<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_66-2\">\t\t\t<label  for=\"field_i2htb-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[66][]\" id=\"field_i2htb-2\" value=\"Sugar\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Sucre<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_66-3\">\t\t\t<label  for=\"field_i2htb-3\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[66][]\" id=\"field_i2htb-3\" value=\"Acids\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Acides<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_66-4\">\t\t\t<label  for=\"field_i2htb-4\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[66][]\" id=\"field_i2htb-4\" value=\"Chewing\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Mastication<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_66-5\">\t\t\t<label  for=\"field_i2htb-5\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[66][]\" id=\"field_i2htb-5\" value=\"None\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Aucun<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_67_container\" class=\"frm_form_field  frm_html_container form-field\">\n<h5>M\u00c2CHOIRES<\/h5>\n<\/div>\n<div id=\"frm_field_68_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div  id=\"field_afytk_label\" class=\"frm_primary_label\">Serrez-vous ou grincez-vous des dents ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_afytk_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_68-0\">\t\t\t<label  for=\"field_afytk-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[68]\" id=\"field_afytk-0\" value=\"Yes\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_68-1\">\t\t\t<label  for=\"field_afytk-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[68]\" id=\"field_afytk-1\" value=\"No\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Non<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_69_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div  id=\"field_was3i_label\" class=\"frm_primary_label\">Avez-vous des craquements, des claquements ou des douleurs lorsque vous ouvrez la m\u00e2choire ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_was3i_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_69-0\">\t\t\t<label  for=\"field_was3i-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[69]\" id=\"field_was3i-0\" value=\"Yes\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_69-1\">\t\t\t<label  for=\"field_was3i-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[69]\" id=\"field_was3i-1\" value=\"No\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Non<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_70_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div  id=\"field_71vwl_label\" class=\"frm_primary_label\">Avez-vous des difficult\u00e9s \u00e0 m\u00e2cher ou m\u00e2chez-vous fr\u00e9quemment d'un seul c\u00f4t\u00e9 ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_71vwl_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_70-0\">\t\t\t<label  for=\"field_71vwl-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[70]\" id=\"field_71vwl-0\" value=\"Yes\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_70-1\">\t\t\t<label  for=\"field_71vwl-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[70]\" id=\"field_71vwl-1\" value=\"No\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Non<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_71_container\" class=\"frm_form_field  frm_html_container form-field\">\n<h5>HABITUDES<\/h5>\n<\/div>\n<div id=\"frm_field_72_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_first frm_three_col\">\r\n\t<div  id=\"field_ajsz4_label\" class=\"frm_primary_label\">Avez-vous eu dans le pass\u00e9 ou avez-vous actuellement l'une des habitudes suivantes\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_ajsz4_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_72-0\">\t\t\t<label  for=\"field_ajsz4-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[72][]\" id=\"field_ajsz4-0\" value=\"Thumb sucking\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   aria-required=\"true\"  \/> Sucer le pouce<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_72-1\">\t\t\t<label  for=\"field_ajsz4-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[72][]\" id=\"field_ajsz4-1\" value=\"Biting your tongue, lip or cheek\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Se mordre la langue, la l\u00e8vre ou la joue<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_72-2\">\t\t\t<label  for=\"field_ajsz4-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[72][]\" id=\"field_ajsz4-2\" value=\"Playing a musical wind instrument\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Jouer d'un instrument de musique \u00e0 vent<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_72-3\">\t\t\t<label  for=\"field_ajsz4-3\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[72][]\" id=\"field_ajsz4-3\" value=\"Biting your nails\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Se ronger les ongles<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_72-4\">\t\t\t<label  for=\"field_ajsz4-4\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[72][]\" id=\"field_ajsz4-4\" value=\"Chewing pencils, glasses or pens\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> M\u00e2cher des crayons, des lunettes ou des stylos<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_72-5\">\t\t\t<label  for=\"field_ajsz4-5\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[72][]\" id=\"field_ajsz4-5\" value=\"Crunch ice cubes\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Croquer des gla\u00e7ons<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_72-6\">\t\t\t<label  for=\"field_ajsz4-6\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[72][]\" id=\"field_ajsz4-6\" value=\"None\"  data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Aucun<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_73_container\" class=\"frm_form_field  frm12 frm_first frm_html_container form-field\">\n<h5>DENTISTERIE ESTH\u00c9TIQUE<\/h5>\n<\/div>\n<div id=\"frm_field_74_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div  id=\"field_j6br7_label\" class=\"frm_primary_label\">Dans un large sourire, vos dents sont-elles toutes de la m\u00eame couleur ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_j6br7_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_74-0\">\t\t\t<label  for=\"field_j6br7-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[74]\" id=\"field_j6br7-0\" value=\"Yes\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_74-1\">\t\t\t<label  for=\"field_j6br7-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[74]\" id=\"field_j6br7-1\" value=\"No\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Non<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_75_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div  id=\"field_ukwhb_label\" class=\"frm_primary_label\">Aimeriez-vous avoir des dents plus blanches ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_ukwhb_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_75-0\">\t\t\t<label  for=\"field_ukwhb-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[75]\" id=\"field_ukwhb-0\" value=\"Yes\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_75-1\">\t\t\t<label  for=\"field_ukwhb-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[75]\" id=\"field_ukwhb-1\" value=\"No\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Non<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_76_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div  id=\"field_g3oz4_label\" class=\"frm_primary_label\">\u00cates-vous satisfait de l\u2019apparence de vos dents et de vos gencives ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_g3oz4_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_76-0\">\t\t\t<label  for=\"field_g3oz4-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[76]\" id=\"field_g3oz4-0\" value=\"Yes\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_76-1\">\t\t\t<label  for=\"field_g3oz4-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[76]\" id=\"field_g3oz4-1\" value=\"No\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Non<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_77_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div  id=\"field_jgtr7_label\" class=\"frm_primary_label\">Mettez-vous votre main devant votre bouche lorsque vous riez ou souriez ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_jgtr7_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_77-0\">\t\t\t<label  for=\"field_jgtr7-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[77]\" id=\"field_jgtr7-0\" value=\"Yes\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_77-1\">\t\t\t<label  for=\"field_jgtr7-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[77]\" id=\"field_jgtr7-1\" value=\"No\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Non<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_78_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_yi8hw\" id=\"field_yi8hw_label\" class=\"frm_primary_label\">Si vous aviez la possibilit\u00e9 de changer votre sourire, qu\u2019aimeriez-vous changer ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_yi8hw\" name=\"item_meta[78]\" value=\"\"  placeholder=\"e.g. whiter teeth \/ alignment \/ shape \/ replace old restorations\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_79_container\" class=\"frm_form_field  frm_html_container form-field\">\n<h5>DIVERS<\/h5>\n<\/div>\n<div id=\"frm_field_80_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n\t<div  id=\"field_o3ojn_label\" class=\"frm_primary_label\">Avez-vous port\u00e9 un appareil ou un appareil dentaire pour redresser vos dents ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_o3ojn_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_80-0\">\t\t\t<label  for=\"field_o3ojn-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[80]\" id=\"field_o3ojn-0\" value=\"Yes\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_80-1\">\t\t\t<label  for=\"field_o3ojn-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[80]\" id=\"field_o3ojn-1\" value=\"No\"\n\t\t data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Non<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_81_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_6943a\" id=\"field_6943a_label\" class=\"frm_primary_label\">Quelle est votre principale pr\u00e9occupation concernant vos dents ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<textarea name=\"item_meta[81]\" id=\"field_6943a\" rows=\"3\"  placeholder=\"e.g. sensitivity, pain, bleeding gums, aesthetics, chewing discomfort\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-invalid=\"false\"  ><\/textarea>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_82_container\" class=\"frm_form_field form-field  frm_top_container frm12 frm_first\">\r\n\t<label for=\"field_7vvce\" id=\"field_7vvce_label\" class=\"frm_primary_label\">Id\u00e9alement, qu\u2019aimeriez-vous changer dans votre bouche ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<textarea name=\"item_meta[82]\" id=\"field_7vvce\" rows=\"3\"  placeholder=\"e.g. better comfort, better smile, less pain\/sensitivity, improved chewing\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-invalid=\"false\"  ><\/textarea>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_83_container\" class=\"frm_form_field form-field  frm_top_container frm12 frm_first horizontal_radio\">\r\n\t<div  id=\"field_j1x9h_label\" class=\"frm_primary_label\">\u00cates-vous inquiet \u00e0 l\u2019id\u00e9e de recevoir des soins dentaires ?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_j1x9h_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_83-0\">\t\t\t<label  for=\"field_j1x9h-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[83]\" id=\"field_j1x9h-0\" value=\"Not at all\"\n\t\t data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Pas du tout<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_83-1\">\t\t\t<label  for=\"field_j1x9h-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[83]\" id=\"field_j1x9h-1\" value=\"A Little\"\n\t\t data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Un peu<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_83-2\">\t\t\t<label  for=\"field_j1x9h-2\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[83]\" id=\"field_j1x9h-2\" value=\"Moderately\"\n\t\t data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Mod\u00e9r\u00e9ment<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_83-3\">\t\t\t<label  for=\"field_j1x9h-3\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[83]\" id=\"field_j1x9h-3\" value=\"A lot\"\n\t\t data-invmsg=\"[nom_du_champ] n&#039;est pas valide\"   \/> Beaucoup<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_86_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_t9ceh\" id=\"field_t9ceh_label\" class=\"frm_primary_label\">Autres remarques utiles ou importantes\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<textarea name=\"item_meta[86]\" id=\"field_t9ceh\" rows=\"5\"  placeholder=\"e.g. medical alert, previous X-rays, accessibility needs, language preference\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" aria-invalid=\"false\"  ><\/textarea>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_90_container\" class=\"frm_form_field  frm_html_container form-field\">\n<p><strong>Merci beaucoup pour votre coop\u00e9ration.<\/strong><\/p>\n<p><em>Je certifie l'exactitude de ce document et je n'ai rien omis.<\/em><br \/><em>Je signalerai imm\u00e9diatement toute<\/em><br \/><em>modification concernant mon \u00e9tat de sant\u00e9 et mes prescriptions m\u00e9dicales.<\/em><\/p>\n<\/div>\n<div id=\"frm_field_91_container\" class=\"frm_form_field form-field  frm_top_container frm6 frm_first\">\r\n\t<label for=\"field_2mbts\" id=\"field_2mbts_label\" class=\"frm_primary_label\">Date\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_2mbts\" name=\"item_meta[91]\" value=\"09\/21\/2026\"  maxlength=\"10\" data-frmval=\"09\/21\/2026\" data-invmsg=\"[nom_du_champ] n&#039;est pas valide\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_92_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n\t<label for=\"field_tl7nv\" id=\"field_tl7nv_label\" class=\"frm_primary_label\">\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<div class=\"sigPad\" id='sigPad92' style=\"max-width:400px;\">\n\t<div class=\"sig sigWrapper\" style=\"height:150px;border-color:#D0D5DD;--bg-color:#ffffff;--active:#01d3be;--inactive:#EAECF0;--active-text:#ffffff;--inactive-text:#1D2939;--button-margin:22px;--button-size:20px;--button-padding:10px;--button-side-margin:22px;--icon:20px\">\n\n\t\t<ul class=\"sigNav\">\n\t\t\t\t<li class=\"drawIt\">\n\t\t\t\t\t<a href=\"#\" class=\"frm-active-sig-type\" title=\"Dessine-le\" aria-label=\"Dessine-le\">\n\t\t\t\t\t\t<svg  viewBox=\"0 0 22 20\" class=\"frmsvg\">\n\t<title>signature<\/title>\n\t<path d=\"M19.7 2.2A3.5 3.5 0 0 0 14 1.1L1.7 13.4a1 1 0 0 0-.3.4l-1.3 5a.9.9 0 0 0 0 .5 1 1 0 0 0 1 .6l5-1.3c.2 0 .4-.1.5-.3L18.9 6a3.5 3.5 0 0 0 .7-3.8zm-6.8 2.6L15.2 7l-8.6 8.7-2.4-2.4zm-10.7 13l1-3.3L5.4 17zM18 4.2l-.4.5L16.3 6 14 3.7l1.3-1.3A1.7 1.7 0 0 1 18 3.6l-.1.6zM9 17.9h11v1H9v-1z\"><\/path>\n\n<\/svg>\t\t\t\t\t<\/a>\n\t\t\t\t<\/li>\n\t\t\t\t<li class=\"typeIt\">\n\t\t\t\t\t<a href=\"#\" class=\"\" title=\"Tapez-le\" aria-label=\"Tapez-le\">\n\t\t\t\t\t\t<svg  viewBox=\"0 0 22 20\" class=\"frmsvg\">\n\t<title>keyboard<\/title>\n\t<path d=\"M20.6 2.5H2c-1 0-1.9.8-1.9 1.9v11.2c0 1 .8 1.9 1.9 1.9h18.7c1 0 1.9-.8 1.9-1.9V4.4c0-1-.8-1.9-1.9-1.9zm.3 13.1c0 .2-.1.3-.3.3H2a.3.3 0 0 1-.3-.3V4.4c0-.2.1-.3.3-.3h18.7c.2 0 .3.1.3.3v11.2zm-14.3-5V9.4c0-.3-.2-.5-.4-.5H5c-.3 0-.5.2-.5.5v1c0 .3.2.5.5.5h1c.3 0 .5-.2.5-.5zm3.8 0V9.4c0-.3-.2-.5-.5-.5H9c-.3 0-.5.2-.5.5v1c0 .3.2.5.4.5H10c.3 0 .5-.2.5-.5zm3.7 0V9.4c0-.3-.2-.5-.4-.5h-1.1c-.3 0-.5.2-.5.5v1c0 .3.2.5.5.5h1c.3 0 .5-.2.5-.5zm3.8 0V9.4c0-.3-.2-.5-.5-.5h-1c-.3 0-.5.2-.5.5v1c0 .3.2.5.4.5h1.1c.3 0 .5-.2.5-.5zM4.8 7.2v-1c0-.3-.2-.5-.5-.5H3.2c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1.1c.3 0 .5-.2.5-.5zm3.7 0v-1c0-.3-.2-.5-.5-.5H7c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1c.3 0 .5-.2.5-.5zm3.8 0v-1c0-.3-.2-.5-.5-.5h-1.1c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1.1c.3 0 .5-.2.5-.5zm3.7 0v-1c0-.3-.2-.5-.5-.5h-1c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1c.3 0 .5-.2.5-.5zm3.8 0v-1c0-.3-.2-.5-.5-.5h-1.1c-.3 0-.5.2-.5.4v1.1c0 .3.2.5.5.5h1.1c.3 0 .5-.2.5-.5zm-2 6.2V13c0-.3-.2-.5-.6-.5h-12c-.3 0-.6.2-.6.5v.6c0 .3.3.5.7.5h12c.3 0 .6-.2.6-.5z\"><\/path>\n<\/svg>\t\t\t\t\t<\/a>\n\t\t\t\t<\/li>\n\t\t<\/ul>\n\n\t\t<span class=\"frm-typed-drawline\"><\/span>\n\n\t\t<div class=\"typed\">\n\t\t\t<input type=\"text\" name=\"item_meta[92][typed]\" class=\"name\" id=\"field_tl7nv\" autocomplete=\"off\" value=\"\"  style=\"width:400px\" maxlength=\"150\" data-reqmsg=\"[nom_du_champ] ne peut pas \u00eatre vide.\" aria-required=\"true\" class=\"auto_width\" aria-invalid=\"false\" aria-describedby=\"frm_desc_field_tl7nv\"   \/>\n\t\t<\/div>\n\n\t\t<canvas class=\"pad\" data-fieldid=\"92\" data-fieldname=\"item_meta[92]\" width=\"396\" height=\"150\"><\/canvas>\n\t\t<div class=\"clearButton\"><a href=\"#clear\">Claire<\/a><\/div>\n\n\t\t<input type=\"hidden\" name=\"item_meta[92][output]\" class=\"output\" value=\"\" \/>\n\t<\/div>\n<\/div>\n\r\n\t<div class=\"frm_description\" id=\"frm_desc_field_tl7nv\">Signature du patient (ou du tuteur l\u00e9gal)<\/div>\r\n\t\r\n<\/div>\n<div id=\"frm_field_6_container\" class=\"frm_form_field form-field \">\r\n\t<div class=\"frm_submit frm_flex\">\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"   formnovalidate=\"formnovalidate\">Soumettre<\/button>\r\n\r\n\r\n\r\n<\/div>\r\n<\/div>\n<input type=\"hidden\" name=\"item_meta[93]\" id=\"field_ny4vq\" value=\"\" data-frmval=\"\"\/>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t<style>.frm-abandonment-modal * {\n\tbox-sizing: border-box;\n}\n\n.frm-abandonment-modal {\n\tposition: fixed;\n\ttop: 0;\n\tright: 0;\n\tbottom: 0;\n\tleft: 0;\n\tz-index: 1000;\n\tdisplay: flex;\n\tflex-direction: column;\n\talign-items: center;\n\tvisibility: hidden;\n\toverflow: hidden;\n\topacity: 0;\n\t-webkit-overflow-scrolling: touch;\n}\n\n.frm-abandonment-modal .tingle-modal__close {\n\tdisplay: none;\n}\n\n.frm-abandonment-modal .tingle-modal-box {\n\tposition: relative;\n\tflex-shrink: 0;\n\tmargin-top: auto;\n\tmargin-bottom: auto;\n\tmax-width: 345px;\n\tbackground: #fff;\n\topacity: 1;\n\tcursor: auto;\n\tborder-radius: var(--border-radius);\n\twill-change: transform, opacity;\n\tpadding: 1.5rem;\n\tbox-shadow: 1px 1px 11px 2px rgba(0, 0, 0, 0.2);\n}\n\n.frm-abandonment-modal .tingle-modal-box__content h3{\n\tmargin-top: 0;\n}\n\na.frm-abandonment-close {\n\tposition: absolute;\n\ttop: 10px;\n\tright: 5%;\n\ttext-decoration: none;\n\tcolor: currentColor;\n\topacity: .8;\n\tfont-size: 30px;\n\tfont-weight: 300;\n\tline-height: 21px;\n}\n\n.frm-abandonment-btn-invisible {\n\topacity: 0;\n}\n\n.tingle-enabled {\n\tposition: fixed;\n\tright: 0;\n\tleft: 0;\n\toverflow: hidden;\n}\n\n.frm-abandonment-modal.tingle-modal--visible .tingle-modal-box__footer {\n\tbottom: 0;\n}\n\n.frm-abandonment-modal.tingle-modal--visible {\n\tvisibility: visible;\n\topacity: 1;\n\tbackground: 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Office Phone Email address How did you find the office ? 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