{"id":6997,"date":"2026-05-23T13:20:35","date_gmt":"2026-05-23T13:20:35","guid":{"rendered":"https:\/\/talpadent.lu\/medical-and-dental-history\/"},"modified":"2026-05-29T12:44:50","modified_gmt":"2026-05-29T12:44:50","slug":"medical-and-dental-history","status":"publish","type":"page","link":"https:\/\/talpadent.lu\/ro\/medical-and-dental-history\/","title":{"rendered":"ISTORIC MEDICAL SI DENTAR"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"6997\" class=\"elementor elementor-6997 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\">ISTORIC MEDICAL SI DENTAR <\/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_ajax_submit  frm_pro_form \" id=\"form_questionnaire\" >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Chestionar<\/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=\"ec148824e2\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/ro\/wp-json\/wp\/v2\/pages\/6997\" \/><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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> D-na<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> domnisoara<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Dl<\/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\">Nume\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=\"\"  data-reqmsg=\"[nume_c\u00e2mp] nu poate fi gol.\" aria-required=\"true\" data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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\">Prenume\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=\"\"  data-reqmsg=\"[nume_c\u00e2mp] nu poate fi gol.\" aria-required=\"true\" data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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\">Cod po\u0219tal\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=\"\"  data-reqmsg=\"[nume_c\u00e2mp] nu poate fi gol.\" aria-required=\"true\" data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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\">Loca\u0163ie\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=\"\"  data-reqmsg=\"[nume_c\u00e2mp] nu poate fi gol.\" aria-required=\"true\" data-invmsg=\"[nume_c\u00e2mp] este invalid\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_10_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n\t<label for=\"field_oz2a2\" id=\"field_oz2a2_label\" class=\"frm_primary_label\">Num\u0103rul str\u0103zii\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=\"\"  data-reqmsg=\"[nume_c\u00e2mp] nu poate fi gol.\" aria-required=\"true\" data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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\">Profesie\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=\"\"  data-reqmsg=\"[nume_c\u00e2mp] nu poate fi gol.\" aria-required=\"true\" data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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\">Data na\u0219terii\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=\"\"  data-reqmsg=\"[nume_c\u00e2mp] nu poate fi gol.\" aria-required=\"true\" data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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\">Cod numeric personal\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=\"\"  data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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\">Compania de securitate\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=\"\"  data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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\">Asigurare complementara\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=\"\"  data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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=\"\"  data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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\">Telefon de acas\u0103\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=\"\"  data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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}$\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_19_container\" class=\"frm_form_field form-field  frm_top_container frm4\">\r\n\t<label for=\"field_4cxnh\" id=\"field_4cxnh_label\" class=\"frm_primary_label\">Telefon de birou\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input type=\"tel\" id=\"field_4cxnh\" name=\"item_meta[19]\" value=\"\"  data-invmsg=\"[nume_c\u00e2mp] este invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\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\">Adresa de e-mail\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=\"\"  data-reqmsg=\"[nume_c\u00e2mp] nu poate fi gol.\" aria-required=\"true\" data-invmsg=\"V\u0103 rug\u0103m s\u0103 introduce\u021bi o adres\u0103 de email valid\u0103\" 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\">Cum a\u021bi g\u0103sit biroul? (internet, Doctena, prieteni\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=\"\"  data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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>ISTORIC MEDICAL<\/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\">Numele, adresa \u0219i num\u0103rul de telefon al medicului dumneavoastr\u0103\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\"  data-reqmsg=\"[nume_c\u00e2mp] nu poate fi gol.\" aria-required=\"true\" data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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\">C\u00e2nd a fost ultimul t\u0103u examen medical\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=\"\"  data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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 horizontal_radio\">\r\n\t<div  id=\"field_ujiy6_label\" class=\"frm_primary_label\">A\u021bi experimentat vreo schimbare \u00een starea dumneavoastr\u0103 de s\u0103n\u0103tate \u00een ultimul an?\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Da<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Nu<\/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\">V\u0103 rug\u0103m s\u0103 bifa\u021bi fiecare dintre urm\u0103toarele boli sau probleme pe care le-a\u021bi fi putut avea \u00een trecut sau pe care le ave\u021bi \u00een prezent\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   aria-required=\"true\"  \/> Depresie<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Boala de ficat<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Proteze (altele dec\u00e2t cele dentare)<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Astm<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Boli de inima<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Reumatismul articular acut<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Chirurgie Plastic\u0103<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Boal\u0103 de s\u00e2nge<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> HIV pozitiv<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Tulbur\u0103ri hormonale<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Boli venerice<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Sinuzit\u0103 repetat\u0103<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Diabet<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Edem (umfl\u0103turi)<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Sincop\u0103, Ame\u021beli<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Glaucom<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Stimulator cardiac<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> tiroida<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Hepatita A, B sau 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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Pierderea cuno\u0219tin\u021bei<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Probleme cu rinichii<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Leziuni cardiace congenitale<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Probleme circulatorii<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Tumor\u0103 malign\u0103<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Ulcere stomacale<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Probleme nervoase<\/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=\"Other Diseases\"  data-frmlimit=\"27\"  data-frmmin=\"1\"  data-reqmsg=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Alte Boli<\/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\">A\u021bi avut vreodat\u0103 s\u00e2nger\u0103ri anormale \u00een timpul unei opera\u021bii sau al unui accident?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_ii0t4_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_24-0\">\t\t\t<label  for=\"field_ii0t4-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[24]\" id=\"field_ii0t4-0\" value=\"Yes\"\n\t\t data-reqmsg=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Da<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Nu<\/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\">A\u021bi fost vreodat\u0103 tratat cu radioterapie sau chimioterapie?\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Da<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Nu<\/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\">Lua\u021bi vreun medicament \u00een prezent?\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Da<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Nu<\/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\">Care dintre ele\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   aria-required=\"true\"  \/> Antibiotice<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Aspirin\u0103<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Antihistaminice<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Tratament pentru tensiunea arterial\u0103<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Tranchilizant<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Cortizon<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Insulin\u0103<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Bifosfonat<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Di-Hydan (antiepileptic)<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Anticoagulant<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_28-10\">\t\t\t<label  for=\"field_5qyr4-10\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[28][]\" id=\"field_5qyr4-10\" value=\"Other\"  data-frmlimit=\"12\"  data-frmmin=\"1\"  data-reqmsg=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Alte<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\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\">E\u0219ti alergic la anumite produse sau medicamente?\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Da<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Nu<\/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\">Care dintre ele\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   aria-required=\"true\"  \/> Anestezistul local al dentistului<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Iod \u0219i deriva\u021bi<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> 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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Antibiotic<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> 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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Barbituriques<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_30-6\">\t\t\t<label  for=\"field_6zw98-6\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[30][]\" id=\"field_6zw98-6\" value=\"Anti-inflammatory or Aspirin\"  data-frmlimit=\"15\"  data-frmmin=\"1\"  data-reqmsg=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Antiinflamator sau Aspirina<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Penicilin\u0103<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Neuroleptic sau somnifer<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Codeina<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\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\">Fuma\u021bi?\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Du<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Nu<\/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\">Num\u0103rul de \u021big\u0103ri\/zi \u0219i durata acestora\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=\"\"  data-reqmsg=\"[nume_c\u00e2mp] nu poate fi gol.\" aria-required=\"true\" data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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\">Doamn\u0103, domni\u0219oar\u0103, sunte\u021bi \u00eens\u0103rcinat\u0103?\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=\"[nume_c\u00e2mp] este invalid\"   \/> Du<\/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=\"[nume_c\u00e2mp] este invalid\"   \/> Nu<\/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\">C\u00e2te luni\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=\"\"  data-reqmsg=\"[nume_c\u00e2mp] nu poate fi gol.\" aria-required=\"true\" data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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\">Iei pilula \u00een prezent?\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Du<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Nu<\/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\">C\u00e2te luni\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=\"[nume_c\u00e2mp] nu poate fi gol.\" aria-required=\"true\" data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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\">Urma\u021bi vreun tratament pentru osteoporoz\u0103 sau o alt\u0103 boal\u0103 osoas\u0103?\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Du<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Nu<\/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\">Ce fel de medicamente lua\u021bi?\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   aria-required=\"true\"  \/> Hormonii<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Estrogenii<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Bifosfona\u021bi<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\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\">Dac\u0103 crede\u021bi c\u0103 ave\u021bi orice alt\u0103 boal\u0103 sau orice alt\u0103 problem\u0103 care nu este men\u021bionat\u0103 \u00een lista de mai sus \u0219i care ne-ar putea ajuta s\u0103 v\u0103 trat\u0103m \u00een cele mai bune condi\u021bii, v\u0103 rug\u0103m s\u0103 o specifica\u021bi aici.\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\"  data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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>ISTORIC DENTAR<\/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\">C\u00e2nd a fost ultimul t\u0103u control stomatologic\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=\"\"  data-reqmsg=\"[nume_c\u00e2mp] nu poate fi gol.\" aria-required=\"true\" data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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\">Care este motivul consult\u0103rii dumneavoastr\u0103?\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=\"\"  data-reqmsg=\"[nume_c\u00e2mp] nu poate fi gol.\" aria-required=\"true\" data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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\">\u00cen timpul vizitelor dumneavoastr\u0103 anterioare la dentist, a\u021bi \u00eent\u00e2mpinat dificult\u0103\u021bi deosebite? Dac\u0103 da, care?\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=\"\"  data-reqmsg=\"[nume_c\u00e2mp] nu poate fi gol.\" aria-required=\"true\" data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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>IGIEN\u0102 DENTAR\u0102<\/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\">Folose\u0219ti o periu\u021b\u0103 de cap\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   aria-required=\"true\"  \/> Electric<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Manual<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Greu<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Mediu<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Moale<\/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\">C\u00e2nd te speli pe din\u021bi?\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   aria-required=\"true\"  \/> Diminea\u0163\u0103<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> dup\u0103-amiaz\u0103<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Sear\u0103<\/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\">C\u00e2t de des \u00ee\u021bi schimbi periu\u021ba de din\u021bi?\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=\"\"  data-reqmsg=\"[nume_c\u00e2mp] nu poate fi gol.\" aria-required=\"true\" data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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\">Folose\u0219ti\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> A\u021b\u0103 dentar\u0103<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Periu\u021be interdentare<\/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\">Sim\u021bi c\u0103 ai respira\u021bie ur\u00e2t mirositoare \/ gust ur\u00e2t \u00een \u200b\u200bgur\u0103?\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Du<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Nu<\/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>GUM\u0102<\/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\">Ai observat c\u0103 din\u021bii \u021bi s-au separat dup\u0103 un timp?\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Du<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Nu<\/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\">\u00ce\u021bi s\u00e2ngereaz\u0103 gingiile dup\u0103 ce te speli pe din\u021bi sau chiar 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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Du<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Nu<\/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\">\u021ai-ai tratat vreodat\u0103 gingiile?\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Du<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Nu<\/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\">De\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Medicamente<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Detartraj<\/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>DIN\u021aI<\/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\">\u021ai-ai extras vreodat\u0103 din\u021bi?\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Du<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Nu<\/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\">De ce\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   aria-required=\"true\"  \/> Carie<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_59-1\">\t\t\t<label  for=\"field_8r99-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[59][]\" id=\"field_8r99-1\" value=\"Infection or Abscess\"  data-reqmsg=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Infec\u021bie sau abces<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Retragerea gingiilor<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> M\u0103sea de minte<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Fractur\u0103<\/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\">Din\u021bii extra\u0219i au fost \u00eenlocui\u021bi?\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Du<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Nu<\/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\">De\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   aria-required=\"true\"  \/> Un pod fix<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Protez\u0103 dentar\u0103<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Un implant<\/label><\/div>\n<\/div>\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\">Cum te sim\u021bi cu protezele tale actuale?\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=\"\"  data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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\">\u00cen ceea ce prive\u0219te utilizarea metalelor \u00een gur\u0103, ave\u021bi preferin\u021be anume?\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Du<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Nu<\/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\">Dac\u0103 nu, din ce motiv?\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=\"\"  data-invmsg=\"[nume_c\u00e2mp] este invalid\" aria-invalid=\"false\"   \/>\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\">Dac\u0103 da, care\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=\"\"  data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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\">Ai din\u021bi sensibili la\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   aria-required=\"true\"  \/> Cald<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Rece<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Zah\u0103r<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Acizi<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> mestecat<\/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>F\u0102LCI<\/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\">Str\u00e2nge\u021bi sau scr\u00e2\u0219ni\u021bi din din\u021bi?\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Du<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Nu<\/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\">Sim\u021bi trosnituri, clicuri sau dureri c\u00e2nd deschizi maxilarul?\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Du<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Nu<\/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\">Ave\u021bi dificult\u0103\u021bi \u00een a mesteca sau mesteca\u021bi frecvent doar pe o singur\u0103 parte?\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Du<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Nu<\/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>OBICEIURI<\/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\">A\u021bi avut \u00een trecut sau ave\u021bi \u00een prezent oricare dintre urm\u0103toarele obiceiuri\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   aria-required=\"true\"  \/> Suge degetul mare<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Mu\u0219c\u0103tura limbii, buzei sau obrazului<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> C\u00e2nt\u00e2nd la un instrument muzical de suflat<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> S\u0103-\u021bi mu\u0219ti unghiile<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Mestecarea creioanelor, ochelarilor sau pixurilor<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Crunch cuburi de ghea\u021b\u0103<\/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>STOMATOLOGIE ESTETIC\u0102<\/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\">\u00centr-un z\u00e2mbet larg, din\u021bii t\u0103i au to\u021bi aceea\u0219i culoare?\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Du<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Nu<\/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\">\u021ai-ar pl\u0103cea s\u0103 ai din\u021bi mai albi?\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Du<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Nu<\/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\">E\u0219ti mul\u021bumit de aspectul din\u021bilor \u0219i gingiilor tale?\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Du<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Nu<\/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\">\u00ce\u021bi pui m\u00e2na \u00een fa\u021ba gurii c\u00e2nd r\u00e2zi sau z\u00e2mbe\u0219ti?\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Du<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Nu<\/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\">Dac\u0103 ai avea posibilitatea s\u0103-\u021bi schimbi z\u00e2mbetul, ce \u021bi-ar pl\u0103cea s\u0103 schimbi?\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=\"\"  data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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>DIVERSE<\/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\">Ai purtat vreun aparat sau aparat dentar pentru a-\u021bi \u00eendrepta din\u021bii?\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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Du<\/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=\"[nume_c\u00e2mp] nu poate fi gol.\" data-invmsg=\"[nume_c\u00e2mp] este invalid\"   \/> Nu<\/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\">Care este principala ta preocupare legat\u0103 de din\u021bii t\u0103i?\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\"  data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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\">Ideal, ce ai vrea s\u0103 schimbi \u00een gura ta?\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\"  data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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\">E\u0219ti \u00eengrijorat\/\u0103 \u00een leg\u0103tur\u0103 cu \u00eengrijirea dentar\u0103?\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=\"[nume_c\u00e2mp] este invalid\"   \/> Deloc<\/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=\"[nume_c\u00e2mp] este invalid\"   \/> Pu\u021bin<\/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=\"[nume_c\u00e2mp] este invalid\"   \/> Moderat<\/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=\"[nume_c\u00e2mp] este invalid\"   \/> multe<\/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\">Alte observa\u021bii utile sau importante\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\"  data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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>V\u0103 mul\u021bumesc foarte mult pentru cooperare.<\/strong><\/p>\n<p><em>Certific exactitatea acestui document \u0219i nu am omis nimic.<\/em><br \/><em>Voi raporta imediat orice<\/em><br \/><em>modificare privind starea mea de s\u0103n\u0103tate \u0219i prescrip\u021biile mele medicale.<\/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\">Dat\u0103\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=\"[data]\"  maxlength=\"10\" data-frmval=\"[data]\" data-invmsg=\"[nume_c\u00e2mp] este invalid\" 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_top_container frm6\">\r\n\t<label for=\"field_tl7nv\" id=\"field_tl7nv_label\" class=\"frm_primary_label\">\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<div class=\"sigPad\" id='sigPad92' style=\"max-width:400px;\">\n\t<div class=\"sig sigWrapper\" style=\"height:150px;border-color:#D0D5DD;--bg-color:#ffffff;--active:#01d3be;--inactive:#EAECF0;--active-text:#ffffff;--inactive-text:#1D2939;--button-margin:22px;--button-size:20px;--button-padding:10px;--button-side-margin:22px;--icon:20px\">\n\n\t\t<ul class=\"sigNav\">\n\t\t\t\t<li class=\"drawIt\">\n\t\t\t\t\t<a href=\"#\" class=\"frm-active-sig-type\" title=\"Deseneaz\u0103-l\" aria-label=\"Deseneaz\u0103-l\">\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=\"Tasta\u021bi-l\" aria-label=\"Tasta\u021bi-l\">\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\" class=\"auto_width\" aria-invalid=\"false\"   \/>\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\">Clar<\/a><\/div>\n\n\t\t<input type=\"hidden\" name=\"item_meta[92][output]\" class=\"output\" value=\"\" \/>\n\t<\/div>\n<\/div>\n\r\n\t<div class=\"frm_description\" id=\"frm_desc_field_tl7nv\">Semn\u0103tura pacientului (sau a tutorelui legal)<\/div>\r\n\t\r\n<\/div>\n<div id=\"frm_field_6_container\" class=\"frm_form_field form-field \">\r\n\t<div class=\"frm_submit frm_flex\">\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"   formnovalidate=\"formnovalidate\">Trimite\u021bi<\/button>\r\n\r\n\r\n\r\n<\/div>\r\n<\/div>\n<input type=\"hidden\" name=\"item_meta[93]\" id=\"field_ny4vq\" value=\"\" data-frmval=\"\"\/>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t<style>.frm-abandonment-modal * {\n\tbox-sizing: border-box;\n}\n\n.frm-abandonment-modal {\n\tposition: fixed;\n\ttop: 0;\n\tright: 0;\n\tbottom: 0;\n\tleft: 0;\n\tz-index: 1000;\n\tdisplay: flex;\n\tflex-direction: column;\n\talign-items: center;\n\tvisibility: hidden;\n\toverflow: hidden;\n\topacity: 0;\n\t-webkit-overflow-scrolling: touch;\n}\n\n.frm-abandonment-modal .tingle-modal__close {\n\tdisplay: none;\n}\n\n.frm-abandonment-modal .tingle-modal-box {\n\tposition: relative;\n\tflex-shrink: 0;\n\tmargin-top: auto;\n\tmargin-bottom: auto;\n\tmax-width: 345px;\n\tbackground: #fff;\n\topacity: 1;\n\tcursor: auto;\n\tborder-radius: var(--border-radius);\n\twill-change: transform, opacity;\n\tpadding: 1.5rem;\n\tbox-shadow: 1px 1px 11px 2px rgba(0, 0, 0, 0.2);\n}\n\n.frm-abandonment-modal .tingle-modal-box__content h3{\n\tmargin-top: 0;\n}\n\na.frm-abandonment-close {\n\tposition: absolute;\n\ttop: 10px;\n\tright: 5%;\n\ttext-decoration: none;\n\tcolor: currentColor;\n\topacity: .8;\n\tfont-size: 30px;\n\tfont-weight: 300;\n\tline-height: 21px;\n}\n\n.frm-abandonment-btn-invisible {\n\topacity: 0;\n}\n\n.tingle-enabled {\n\tposition: fixed;\n\tright: 0;\n\tleft: 0;\n\toverflow: hidden;\n}\n\n.frm-abandonment-modal.tingle-modal--visible .tingle-modal-box__footer {\n\tbottom: 0;\n}\n\n.frm-abandonment-modal.tingle-modal--visible {\n\tvisibility: visible;\n\topacity: 1;\n\tbackground: rgba(0, 0, 0, 0.5);\n}\n\n.frm-abandonment-modal.tingle-modal--visible .tingle-modal-box {\n\tanimation: abdn-scale .2s cubic-bezier(.68, -.55, .265, 1.55) forwards;\n}\n\n.tingle-modal--overflow {\n\toverflow-y: scroll;\n\tpadding-top: 8px;\n}\n\n@keyframes abdn-scale {\n\t0% {\n\t\topacity: 0;\n\t\ttransform: scale(.9);\n\t}\n\t100% {\n\t\topacity: 1;\n\t\ttransform: scale(1);\n\t}\n}<\/style><input type=\"hidden\" name=\"auto_save\" value=\"20000\"\/><input name=\"frm_state\" type=\"hidden\" value=\"505xh7OciK\/9aWYxohyEd3yP9tFtpSk8nA2HRyHZIIs=\" 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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-6997","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.8 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>ISTORIC MEDICAL SI DENTAR - 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\/ro\/medical-and-dental-history\/\" \/>\n<meta property=\"og:locale\" content=\"ro_RO\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"ISTORIC MEDICAL SI DENTAR - Talpa\" \/>\n<meta property=\"og:description\" content=\"Questionnaire ISTORIC MEDICAL SI DENTAR 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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