{"id":6995,"date":"2026-05-23T13:20:35","date_gmt":"2026-05-23T13:20:35","guid":{"rendered":"https:\/\/talpadent.lu\/medical-and-dental-history\/"},"modified":"2026-05-29T12:44:49","modified_gmt":"2026-05-29T12:44:49","slug":"medical-and-dental-history","status":"publish","type":"page","link":"https:\/\/talpadent.lu\/lb\/medical-and-dental-history\/","title":{"rendered":"MEDICAL AN DENTAL GESCHICHT"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"6995\" class=\"elementor elementor-6995 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\">MEDICAL AN DENTAL GESCHICHT <\/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=\"2fa8e2001d\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/lb\/wp-json\/wp\/v2\/pages\/6995\" \/><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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> 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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Miss<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> H\u00e4r<\/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\">Familljennumm\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" aria-required=\"true\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" 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\">Virnumm\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" aria-required=\"true\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" 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\">Postleitzuel\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" aria-required=\"true\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" 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\">Uertschaft\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" aria-required=\"true\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" 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\">Strooss Zuel\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" aria-required=\"true\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" 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\">Beruff\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" aria-required=\"true\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" 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\">Gebuertsdatum\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" aria-required=\"true\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" 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\">Sozialvers\u00e9cherungsnummer\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=\"[Feldnumm] ass ong\u00eblteg\" 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\">\u00c4r Krankekeess\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=\"[Feldnumm] ass ong\u00eblteg\" 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\">Zousazvers\u00e9cherung\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=\"[Feldnumm] ass ong\u00eblteg\" 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=\"[Feldnumm] ass ong\u00eblteg\" 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\">Home Telefon\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=\"[Feldnumm] ass ong\u00eblteg\" 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}$\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_19_container\" class=\"frm_form_field form-field  frm_top_container frm4\">\r\n\t<label for=\"field_4cxnh\" id=\"field_4cxnh_label\" class=\"frm_primary_label\">B\u00fcro Telefon\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"tel\" id=\"field_4cxnh\" name=\"item_meta[19]\" value=\"\"  placeholder=\"e.g. +352 27 00 00\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\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\">Email Adress\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" aria-required=\"true\" data-invmsg=\"Gitt w.e.g. eng g\u00fclteg E-Mailadress an\" 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\">W\u00e9i hutt Dir eise Cabinet fonnt? (Internet, Doctena, Fr\u00ebnn\u2026)\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=\"[Feldnumm] ass ong\u00eblteg\" 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>MEDIZINESCH GESCHICHT<\/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\">De Familljennumm, d'Adress an d'Telefonsnummer vun \u00c4rem Dokter\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" aria-required=\"true\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" 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\">W\u00e9ini war \u00c4r lescht medizinesch Untersuchung\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=\"[Feldnumm] ass ong\u00eblteg\" 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\">Hutt Dir am leschte Joer \u00c4nnerungen an \u00c4rer Gesondheet gemierkt?\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Jo<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Nee<\/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\">Maacht w.e.g. e Kr\u00e4izchen bei all de folgende Krankheeten oder Problemer, d\u00e9i Dir an der Vergaangenheet hat oder d\u00e9i Dir am Moment hutt.\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   aria-required=\"true\"  \/> Depressioun<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Liewer Krankheet<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Prothesen (ausser Z\u00e4nnprothesen)<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Asthma<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> H\u00e4erzkrankheeten<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Akut artikul\u00e4r Rhythmus<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Plastesch Chirurgie<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Blutt Krankheet<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> HIV Positiv<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Hormonal St\u00e9ierungen<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Geschlechtskrankheeten<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Widderholl Sinusitis<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Diabetis<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> \u00d6demer (Schwellung)<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Synkope, Schwindel<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Glaukom<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Pacemaker<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Schilddr\u00fcs<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Hepatitis A, B oder 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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Verloscht vum Bewosstsinn<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Nier Problemer<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Kongenital H\u00e4erzschued<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Kreislaufproblemer<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Malignen Tumor<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Magengeschw\u00eber<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Nerv\u00f6s Problemer<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Keng<\/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\">Hutt Dir jeemools anormal Blutungen w\u00e4hrend enger Operatioun oder engem Accident gehat?\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Jo<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Nee<\/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\">Sidd Dir jeemools mat Stralung oder Chemotherapie behandelt ginn?\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Jo<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Nee<\/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\">H\u00eblt Dir am Moment Medikamenter?\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Jo<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Nee<\/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\">W\u00e9i eng\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   aria-required=\"true\" aria-describedby=\"frm_desc_field_5qyr4\"  \/> Antibiotike<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" aria-describedby=\"frm_desc_field_5qyr4\"   \/> Aspirin<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" aria-describedby=\"frm_desc_field_5qyr4\"   \/> Antihistamin<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" aria-describedby=\"frm_desc_field_5qyr4\"   \/> Behandlung fir Blutdrock<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" aria-describedby=\"frm_desc_field_5qyr4\"   \/> Tranquilizer<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" aria-describedby=\"frm_desc_field_5qyr4\"   \/> Cortison<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" aria-describedby=\"frm_desc_field_5qyr4\"   \/> Insulin<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" aria-describedby=\"frm_desc_field_5qyr4\"   \/> Biphosphonat<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" aria-describedby=\"frm_desc_field_5qyr4\"   \/> Di-Hydan (Anti-Epileptikum)<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" aria-describedby=\"frm_desc_field_5qyr4\"   \/> Antikoagulant<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" aria-describedby=\"frm_desc_field_5qyr4\"   \/> Aner<\/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\">Aner Medikamenter\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=\"[Feldnumm] 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\">Sidd Dir allergesch g\u00e9int best\u00ebmmt Produkter oder Medikamenter?\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Jo<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Nee<\/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\">W\u00e9i eng\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   aria-required=\"true\" aria-describedby=\"frm_desc_field_6zw98\"  \/> Lokalan\u00e4sthesie vum Z\u00e4nndokter<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" aria-describedby=\"frm_desc_field_6zw98\"   \/> Jod an Derivater<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" aria-describedby=\"frm_desc_field_6zw98\"   \/> Metal<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" aria-describedby=\"frm_desc_field_6zw98\"   \/> Antibiotikum<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" 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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" aria-describedby=\"frm_desc_field_6zw98\"   \/> Barbitus<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" aria-describedby=\"frm_desc_field_6zw98\"   \/> Entz\u00fcndungshemmend oder Aspirin<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" aria-describedby=\"frm_desc_field_6zw98\"   \/> Penicillin<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" aria-describedby=\"frm_desc_field_6zw98\"   \/> Neuroleptikum oder Schlofpille<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" aria-describedby=\"frm_desc_field_6zw98\"   \/> Codeine<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" aria-describedby=\"frm_desc_field_6zw98\"   \/> Aner<\/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\">Aner Produkter oder Medikamenter\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=\"[Feldnumm] ass ong\u00eblteg\" 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\">F\u00ebmmt Dir?\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Jo<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Nee<\/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\">Zuel vun Zigaretten\/Dag a fir w\u00e9i laang\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" aria-required=\"true\" data-invmsg=\"Zuel vun Zigaretten\/Dag a fir w\u00e9i laang ass ong\u00eblteg\" 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, Madame, sidd Dir schwanger?\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=\"[Feldnumm] ass ong\u00eblteg\"   \/> Jo<\/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=\"[Feldnumm] ass ong\u00eblteg\"   \/> Nee<\/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\">W\u00e9ivill M\u00e9int\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" aria-required=\"true\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" 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\">Huelst du am Moment d'Pille?\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Jo<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Nee<\/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\">W\u00e9ivill M\u00e9int\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" aria-required=\"true\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" 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\">G\u00ebtt Dir eng Behandlung fir Osteoporose oder eng aner Knochenerkrankung?\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Jo<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Nee<\/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\">Wat fir eng Zort Medikamenter h\u00eblls du?\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   aria-required=\"true\"  \/> Hormone<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> \u00d6strogenen<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Biphosphonaten<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Aner Medikamenter<\/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\">Aner Medikamenter\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=\"[Feldnumm] ass ong\u00eblteg\" 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\">Wann Dir mengt, datt Dir eng aner Krankheet oder en anert Problem hutt, dat net an der L\u00ebscht uewen ernimmt ass, an deen eis h\u00ebllefe k\u00e9int, Iech \u00ebnner de beschte Konditiounen ze behandelen, da gitt dat w.e.g. hei un.\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=\"[Feldnumm] ass ong\u00eblteg\" 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>Z\u00e4nngeschicht<\/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\">W\u00e9ini war \u00c4r lescht Z\u00e4nnuntersuchung\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" aria-required=\"true\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" 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\">Wat ass de Grond fir \u00c4r Consultatioun?\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" aria-required=\"true\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" 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\">Hutt Dir bei \u00c4re fr\u00e9iere Visite beim Z\u00e4nndokter op speziell Schwieregkeeten gestouss? Wann jo, w\u00e9i eng?\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" aria-required=\"true\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" 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>Z\u00e4nnhygiene<\/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\">Benotzt Dir eng Z\u00e4nnb\u00fcrk\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   aria-required=\"true\"  \/> Elektresch<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Manuell<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Schw\u00e9ier<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> M\u00ebttelm\u00e9isseg<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Soft<\/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\">W\u00e9ini botzt Dir \u00c4r Z\u00e4nn?\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   aria-required=\"true\"  \/> Moien<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> M\u00ebtteg<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Owend<\/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\">W\u00e9i dacks wiesselt Dir \u00c4r Z\u00e4nnb\u00fcrk?\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" aria-required=\"true\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" 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\">Benotzt Dir\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Dental Floss<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Interdentalb\u00fcrsten<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_49-2\">\t\t\t<label  for=\"field_c9nu-2\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[49]\" id=\"field_c9nu-2\" value=\"None\"\n\t\t data-reqmsg=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Keng<\/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\">Hues du d'Gefill, datt du schlecht Otem \/ e schlechten Geschmaach am Mond hues?\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Jo<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Nee<\/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>Z\u00c4NNFLEESCH<\/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\">Hues du gemierkt, datt deng Z\u00e4nn no enger Z\u00e4it getrennt sinn?\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Jo<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Nee<\/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\">Bluddt \u00c4ert Z\u00e4nnfleesch no der Z\u00e4nnbotzen, oder souguer spontan?\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Jo<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Nee<\/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\">Hues du schonn emol d\u00e4i Z\u00e4nnfleesch behandelt?\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Jo<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Nee<\/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\">Vun\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Medikamenter<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Entkalking<\/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>Z\u00c4NN<\/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\">Hues du schonn emol Z\u00e4nn erausgezunn?\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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Jo<\/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=\"[Feldnumm] d\u00e4erf net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Nee<\/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\">Wann jo, firwat\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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   aria-required=\"true\"  \/> Karies<\/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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Infektioun oder Abscess<\/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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Z\u00e4nnfleesch zr\u00e9ckz\u00e9ien<\/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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> W\u00e4isheet Zahn<\/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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Fraktur<\/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\">Ginn d\u00e9i extrah\u00e9iert Z\u00e4nn ersat?\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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Jo<\/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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Nee<\/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\">Wann jo, duerch\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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   aria-required=\"true\"  \/> Eng fix Br\u00e9ck<\/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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Geb\u00ebss<\/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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> En Implantat<\/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\">Wann net, aus w\u00e9i engem Grond?\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=\"[Feldnumm] ass ong\u00eblteg\" 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\">W\u00e9i fillt Dir Iech mat \u00c4ren aktuellen Prothesen?\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=\"[Feldnumm] ass ong\u00eblteg\" 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\">Wat d'Benotzung vu Metaller an \u00c4rem Mond ugeet, hutt Dir speziell Virl\u00e9iften?\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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Jo<\/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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Nee<\/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\">Wann jo, w\u00e9i eng\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=\"[Feldnumm] ass ong\u00eblteg\" 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\">Hutt Dir sensibel Z\u00e4nn ze\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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   aria-required=\"true\"  \/> Warm<\/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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Keelt<\/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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Zocker<\/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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Saieren<\/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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Kauen<\/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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Keng<\/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>KIEFEREN<\/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\">Knascht Dir \u00c4r Z\u00e4nn oder dr\u00e9ckt Dir?\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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Jo<\/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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Nee<\/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\">Hutt Dir R\u00ebss, Klick oder P\u00e9ng wann Dir \u00c4re Kiefer opmaacht?\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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Jo<\/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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Nee<\/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\">Hutt Dir Schwieregkeeten ze kauen oder kauen Dir dacks n\u00ebmmen op enger S\u00e4it?\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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Jo<\/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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Nee<\/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>Gewunnechten<\/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\">Hutt Dir an der Vergaangenheet oder hutt Dir am Moment eng vun de folgende Gewunnechten\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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   aria-required=\"true\"  \/> Daumen suckelen<\/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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Bitt \u00c4r Zong, Lip oder Wang<\/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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> E musikalescht Blasinstrument spillen<\/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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Bitt den Neel<\/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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Kauen Bl\u00e4ist\u00ebfter, Br\u00ebller oder St\u00ebfter<\/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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Crunch \u00c4iswierfelen<\/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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Keng<\/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>\u00c4STH\u00c9ISCH Z\u00c4NNHEET<\/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\">An engem breede Laachen, sinn \u00c4r Z\u00e4nn all d\u00e9iselwecht Faarf?\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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Jo<\/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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Nee<\/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\">W\u00ebllt Dir m\u00e9i w\u00e4iss Z\u00e4nn hunn?\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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Jo<\/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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Nee<\/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\">Sidd Dir zefridden mat \u00c4rem Z\u00e4nn an \u00c4rem Z\u00e4nnfleesch?\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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Jo<\/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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Nee<\/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\">Hues du d'Hand virun de Mond, wann Dir laacht oder laacht?\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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Jo<\/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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Nee<\/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\">Wann Dir d'M\u00e9iglechkeet h\u00e4tt \u00c4ert Laachen z'\u00e4nneren, wat w\u00ebllt Dir \u00e4nneren?\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=\"[Feldnumm] ass ong\u00eblteg\" 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>Verschidde<\/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\">Hutt Dir en Apparat oder Klamere gedroen fir \u00c4r Z\u00e4nn ze riichten?\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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Jo<\/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=\"[Feldnumm] kann net eidel sinn.\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\"   \/> Nee<\/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\">Wat ass \u00c4r Haaptsuerg iwwer \u00c4r Z\u00e4nn?\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=\"[Feldnumm] ass ong\u00eblteg\" 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\">Am Idealfall, wat g\u00e9ift Dir g\u00e4ren an \u00c4rem Mond \u00e4nneren?\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=\"[Feldnumm] ass ong\u00eblteg\" 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\">Sidd Dir Angscht vir Z\u00e4nnpfleeg ze kr\u00e9ien?\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=\"[Feldnumm] ass ong\u00eblteg\"   \/> Guer net<\/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=\"[Feldnumm] ass ong\u00eblteg\"   \/> E b\u00ebssen<\/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=\"[Feldnumm] ass ong\u00eblteg\"   \/> M\u00ebttelm\u00e9isseg<\/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=\"[Feldnumm] ass ong\u00eblteg\"   \/> Vill<\/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\">Aner n\u00ebtzlech oder wichteg Bemierkungen\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=\"[Feldnumm] ass ong\u00eblteg\" 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>Villmols Merci fir \u00c4r Zesummenaarbecht.<\/strong><\/p>\n<p><em>Ech best\u00e4tegen d'Genauegkeet vun d\u00ebsem Dokument an ech hunn n\u00e4ischt ewech gelooss.<\/em><br \/><em>Ech w\u00e4ert direkt all<\/em><br \/><em>\u00c4nnerunge betreffend m\u00e4i Gesondheetszoustand a meng medizinesch Virschr\u00ebfte mellen.<\/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\">Daten\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=\"[daten]\"  maxlength=\"10\" data-frmval=\"[daten]\" data-invmsg=\"[Feldnumm] ass ong\u00eblteg\" 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\t\t\t<input  type=\"hidden\" name=\"item_meta[92][delete_saved_image]\" value=\"0\" \/>\n\t\t\t\t\t\t<input  type=\"hidden\" name=\"item_meta[92][content]\" value=\"\" \/>\n\t\t\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=\"Zeechnen Et\" aria-label=\"Zeechnen Et\">\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=\"Typ et\" aria-label=\"Typ et\">\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=\"[Feldnumm] kann net eidel sinn.\" 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\">Kloer<\/a><\/div>\n\n\t\t<input type=\"hidden\" name=\"item_meta[92][output]\" class=\"output\" value=\"\" 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(internet, Doctena, friends\u2026) MEDICAL HISTORY Your doctor\u2019s last name, address and phone [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-6995","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.6 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>MEDICAL AN DENTAL GESCHICHT - Talpa<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/talpadent.lu\/lb\/medical-and-dental-history\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"MEDICAL AN DENTAL GESCHICHT - Talpa\" \/>\n<meta property=\"og:description\" content=\"Questionnaire MEDICAL AN DENTAL GESCHICHT Questionnaire Mrs Miss Mr Last Name First Name ZIP code Location Street Number Profession Date of Birth Social Security Number Security Company Complementary Insurance GSM Home Phone Office Phone Email address How did you find the office ? 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