{"id":1936,"date":"2024-10-14T17:50:01","date_gmt":"2024-10-14T17:50:01","guid":{"rendered":"https:\/\/boutique.steinbergurology.com\/?page_id=1936"},"modified":"2024-11-27T14:25:38","modified_gmt":"2024-11-27T14:25:38","slug":"quiz","status":"publish","type":"page","link":"https:\/\/boutique.steinbergurology.com\/fr\/testosterone\/quiz\/","title":{"rendered":"Formulaire d&rsquo;\u00e9valuation pour la th\u00e9rapie de remplacement de la testost\u00e9rone"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1936\" class=\"elementor elementor-1936 elementor-1585\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-748a3d8 e-flex e-con-boxed e-con e-parent\" data-id=\"748a3d8\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-937c978 e-con-full e-flex e-con e-child\" data-id=\"937c978\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-f75a4fa e-con-full e-flex e-con e-child\" data-id=\"f75a4fa\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-c9bf503 elementor-widget__width-initial elementor-widget-tablet__width-inherit elementor-widget elementor-widget-heading\" data-id=\"c9bf503\" 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\">Merci pour votre paiement.<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-adfb44e elementor-widget__width-initial elementor-widget-tablet__width-inherit elementor-widget elementor-widget-heading\" data-id=\"adfb44e\" 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<p class=\"elementor-heading-title elementor-size-default\">Veuillez r\u00e9pondre aux questions ci-dessous.<\/p>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-7a62c14 elementor-widget__width-initial elementor-widget-tablet__width-inherit elementor-widget elementor-widget-heading\" data-id=\"7a62c14\" 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<p class=\"elementor-heading-title elementor-size-default\">Vos r\u00e9ponses seront envoy\u00e9es \u00e0 notre clinique pour \u00e9valuer votre \u00e9ligibilit\u00e9 \u00e0 la th\u00e9rapie de remplacement de la testost\u00e9rone (TRT).\n<\/p>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-7c7f3b4 elementor-hidden-mobile elementor-widget elementor-widget-spacer\" data-id=\"7c7f3b4\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-196c030 elementor-widget__width-initial elementor-widget-tablet__width-inherit elementor-widget elementor-widget-heading\" data-id=\"196c030\" 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<h1 class=\"elementor-heading-title elementor-size-default\">Formulaire d'\u00e9valuation pour la th\u00e9rapie de remplacement de la testost\u00e9rone<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-19cf1ef uael-gf-btn-size-md 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gfield_required_asterisk\">*<\/span>\u00a0\u00bb indique les champs n\u00e9cessaires<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_4'  action='\/fr\/wp-json\/wp\/v2\/pages\/1936' data-formid='4' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_4_67\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_67'><span class='gform-field-label__text'>Name<\/span><\/label><div class='ginput_container'><input name='input_67' id='input_4_67' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_4_67'>Ce champ n\u2019est utilis\u00e9 qu\u2019\u00e0 des fins de validation et devrait rester inchang\u00e9.<\/div><\/div><div id=\"field_4_13\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">VOS SYMPT\u00d4MES<\/h3><\/div><fieldset id=\"field_4_1\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Avez-vous une baisse de libido ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_1'>\n\t\t\t<div class='gchoice gchoice_4_1_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_1' type='radio' value='Oui'  id='choice_4_1_0' onchange='gformToggleRadioOther( this )'  tabindex='1'  \/>\n\t\t\t\t\t<label for='choice_4_1_0' id='label_4_1_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_1_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_1' type='radio' value='Non'  id='choice_4_1_1' onchange='gformToggleRadioOther( this )'  tabindex='2'  \/>\n\t\t\t\t\t<label for='choice_4_1_1' id='label_4_1_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_31\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Manquez-vous d&#039;\u00e9nergie ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_31'>\n\t\t\t<div class='gchoice gchoice_4_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Oui'  id='choice_4_31_0' onchange='gformToggleRadioOther( this )'  tabindex='3'  \/>\n\t\t\t\t\t<label for='choice_4_31_0' id='label_4_31_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Non'  id='choice_4_31_1' onchange='gformToggleRadioOther( this )'  tabindex='4'  \/>\n\t\t\t\t\t<label for='choice_4_31_1' id='label_4_31_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_32\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Avez-vous une diminution de la force et\/ou de l&#039;endurance ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_32'>\n\t\t\t<div class='gchoice gchoice_4_32_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Oui'  id='choice_4_32_0' onchange='gformToggleRadioOther( this )'  tabindex='5'  \/>\n\t\t\t\t\t<label for='choice_4_32_0' id='label_4_32_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_32_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Non'  id='choice_4_32_1' onchange='gformToggleRadioOther( this )'  tabindex='6'  \/>\n\t\t\t\t\t<label for='choice_4_32_1' id='label_4_32_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_33\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Avez-vous rapetiss\u00e9 ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_33'>\n\t\t\t<div class='gchoice gchoice_4_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Oui'  id='choice_4_33_0' onchange='gformToggleRadioOther( this )'  tabindex='7'  \/>\n\t\t\t\t\t<label for='choice_4_33_0' id='label_4_33_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Non'  id='choice_4_33_1' onchange='gformToggleRadioOther( this )'  tabindex='8'  \/>\n\t\t\t\t\t<label for='choice_4_33_1' id='label_4_33_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_34\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Avez-vous remarqu\u00e9 une diminution du &quot;plaisir de vivre&quot; ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_34'>\n\t\t\t<div class='gchoice gchoice_4_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Oui'  id='choice_4_34_0' onchange='gformToggleRadioOther( this )'  tabindex='9'  \/>\n\t\t\t\t\t<label for='choice_4_34_0' id='label_4_34_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Non'  id='choice_4_34_1' onchange='gformToggleRadioOther( this )'  tabindex='10'  \/>\n\t\t\t\t\t<label for='choice_4_34_1' id='label_4_34_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_35\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00cates-vous triste et\/ou de mauvaise humeur ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_35'>\n\t\t\t<div class='gchoice gchoice_4_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Oui'  id='choice_4_35_0' onchange='gformToggleRadioOther( this )'  tabindex='11'  \/>\n\t\t\t\t\t<label for='choice_4_35_0' id='label_4_35_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Non'  id='choice_4_35_1' onchange='gformToggleRadioOther( this )'  tabindex='12'  \/>\n\t\t\t\t\t<label for='choice_4_35_1' id='label_4_35_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Vos \u00e9rections sont-elles moins fermes ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_36'>\n\t\t\t<div class='gchoice gchoice_4_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Oui'  id='choice_4_36_0' onchange='gformToggleRadioOther( this )'  tabindex='13'  \/>\n\t\t\t\t\t<label for='choice_4_36_0' id='label_4_36_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Non'  id='choice_4_36_1' onchange='gformToggleRadioOther( this )'  tabindex='14'  \/>\n\t\t\t\t\t<label for='choice_4_36_1' id='label_4_36_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_58\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Ressentez-vous des \u00e9rections spontan\u00e9es le matin\u202f?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_58'>\n\t\t\t<div class='gchoice gchoice_4_58_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='Oui'  id='choice_4_58_0' onchange='gformToggleRadioOther( this )'  tabindex='15'  \/>\n\t\t\t\t\t<label for='choice_4_58_0' id='label_4_58_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_58_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='Non'  id='choice_4_58_1' onchange='gformToggleRadioOther( this )'  tabindex='16'  \/>\n\t\t\t\t\t<label for='choice_4_58_1' id='label_4_58_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_59\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00cates-vous capable de maintenir une \u00e9rection suffisante pour avoir des rapports sexuels\u202f?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_59'>\n\t\t\t<div class='gchoice gchoice_4_59_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='Oui'  id='choice_4_59_0' onchange='gformToggleRadioOther( this )'  tabindex='17'  \/>\n\t\t\t\t\t<label for='choice_4_59_0' id='label_4_59_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_59_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='Non'  id='choice_4_59_1' onchange='gformToggleRadioOther( this )'  tabindex='18'  \/>\n\t\t\t\t\t<label for='choice_4_59_1' id='label_4_59_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_60\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Avez-vous des \u00e9rections plus fortes ou plus satisfaisantes lors de la masturbation que pendant une activit\u00e9 sexuelle, ou ne remarquez-vous aucune diff\u00e9rence\u202f?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_60'>\n\t\t\t<div class='gchoice gchoice_4_60_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Oui'  id='choice_4_60_0' onchange='gformToggleRadioOther( this )'  tabindex='19'  \/>\n\t\t\t\t\t<label for='choice_4_60_0' id='label_4_60_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_60_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Non'  id='choice_4_60_1' onchange='gformToggleRadioOther( this )'  tabindex='20'  \/>\n\t\t\t\t\t<label for='choice_4_60_1' id='label_4_60_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_61\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Avez-vous d\u00e9j\u00e0 utilis\u00e9 des m\u00e9dicaments pour la dysfonction \u00e9rectile, tels que le Viagra (sild\u00e9nafil) ou le Cialis (tadalafil)\u202f?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_61'>\n\t\t\t<div class='gchoice gchoice_4_61_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Oui'  id='choice_4_61_0' onchange='gformToggleRadioOther( this )'  tabindex='21'  \/>\n\t\t\t\t\t<label for='choice_4_61_0' id='label_4_61_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_61_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Non'  id='choice_4_61_1' onchange='gformToggleRadioOther( this )'  tabindex='22'  \/>\n\t\t\t\t\t<label for='choice_4_61_1' id='label_4_61_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_62\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Les m\u00e9dicaments ont-ils \u00e9t\u00e9 efficaces ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_62'>\n\t\t\t<div class='gchoice gchoice_4_62_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Oui'  id='choice_4_62_0' onchange='gformToggleRadioOther( this )'  tabindex='23'  \/>\n\t\t\t\t\t<label for='choice_4_62_0' id='label_4_62_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_62_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Non'  id='choice_4_62_1' onchange='gformToggleRadioOther( this )'  tabindex='24'  \/>\n\t\t\t\t\t<label for='choice_4_62_1' id='label_4_62_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_63\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Avez-vous ressenti des effets secondaires li\u00e9s au m\u00e9dicament\u202f?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_63'>\n\t\t\t<div class='gchoice gchoice_4_63_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Oui'  id='choice_4_63_0' onchange='gformToggleRadioOther( this )'  tabindex='25'  \/>\n\t\t\t\t\t<label for='choice_4_63_0' id='label_4_63_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_63_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Non'  id='choice_4_63_1' onchange='gformToggleRadioOther( this )'  tabindex='26'  \/>\n\t\t\t\t\t<label for='choice_4_63_1' id='label_4_63_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_64\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_64'><span class='gform-field-label__text'>Si oui, veuillez pr\u00e9ciser<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_64' id='input_4_64' class='textarea small' tabindex='27'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_37\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Avez-vous remarqu\u00e9 une diminution r\u00e9cente de votre capacit\u00e9 \u00e0 faire du sport ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_37'>\n\t\t\t<div class='gchoice gchoice_4_37_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Oui'  id='choice_4_37_0' onchange='gformToggleRadioOther( this )'  tabindex='28'  \/>\n\t\t\t\t\t<label for='choice_4_37_0' id='label_4_37_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_37_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Non'  id='choice_4_37_1' onchange='gformToggleRadioOther( this )'  tabindex='29'  \/>\n\t\t\t\t\t<label for='choice_4_37_1' id='label_4_37_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_38\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Vous endormez-vous apr\u00e8s le souper ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_38'>\n\t\t\t<div class='gchoice gchoice_4_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Oui'  id='choice_4_38_0' onchange='gformToggleRadioOther( this )'  tabindex='30'  \/>\n\t\t\t\t\t<label for='choice_4_38_0' id='label_4_38_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Non'  id='choice_4_38_1' onchange='gformToggleRadioOther( this )'  tabindex='31'  \/>\n\t\t\t\t\t<label for='choice_4_38_1' id='label_4_38_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_39\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Y a-t-il eu une diminution r\u00e9cente de votre rendement au travail ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_39'>\n\t\t\t<div class='gchoice gchoice_4_39_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Oui'  id='choice_4_39_0' onchange='gformToggleRadioOther( this )'  tabindex='32'  \/>\n\t\t\t\t\t<label for='choice_4_39_0' id='label_4_39_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_39_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Non'  id='choice_4_39_1' onchange='gformToggleRadioOther( this )'  tabindex='33'  \/>\n\t\t\t\t\t<label for='choice_4_39_1' id='label_4_39_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_23\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">VOS ANT\u00c9C\u00c9DENTS M\u00c9DICAUX<\/h3><\/div><div id=\"field_4_40\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_40'><span class='gform-field-label__text'>Poids actuel (lb)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_4_40' type='text' value='' class='large'   tabindex='34'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_41\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_41'><span class='gform-field-label__text'>Taille (po)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_4_41' type='text' value='' class='large'   tabindex='35'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_42\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_42'><span class='gform-field-label__text'>Quelle est votre derni\u00e8re lecture de tension art\u00e9rielle\u202f?<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_4_42' type='text' value='' class='large'   tabindex='36'   aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_50\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Avez-vous des probl\u00e8mes de sant\u00e9 ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_50'>\n\t\t\t<div class='gchoice gchoice_4_50_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Oui'  id='choice_4_50_0' onchange='gformToggleRadioOther( this )'  tabindex='37'  \/>\n\t\t\t\t\t<label for='choice_4_50_0' id='label_4_50_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_50_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Non'  id='choice_4_50_1' onchange='gformToggleRadioOther( this )'  tabindex='38'  \/>\n\t\t\t\t\t<label for='choice_4_50_1' id='label_4_50_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_51\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_51'><span class='gform-field-label__text'>Si oui, veuillez pr\u00e9ciser<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_51' id='input_4_51' class='textarea small' tabindex='39'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Avez-vous des ant\u00e9c\u00e9dents familiaux de crises cardiaques, d\u2019accidents vasculaires c\u00e9r\u00e9braux (AVC) ou de cancer de la prostate\u202f?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_15'>\n\t\t\t<div class='gchoice gchoice_4_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Oui'  id='choice_4_15_0' onchange='gformToggleRadioOther( this )'  tabindex='40'  \/>\n\t\t\t\t\t<label for='choice_4_15_0' id='label_4_15_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Non'  id='choice_4_15_1' onchange='gformToggleRadioOther( this )'  tabindex='41'  \/>\n\t\t\t\t\t<label for='choice_4_15_1' id='label_4_15_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_16\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_16'><span class='gform-field-label__text'>Si oui, qui dans votre famille en a \u00e9t\u00e9 atteint et \u00e0 quel \u00e2ge ont-ils re\u00e7u le diagnostic\u202f?<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_16' id='input_4_16' class='textarea small' tabindex='42'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_52\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Avez-vous des ant\u00e9c\u00e9dents personnels d\u2019apn\u00e9e obstructive du sommeil (AOS)\u202f?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_52'>\n\t\t\t<div class='gchoice gchoice_4_52_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='Oui'  id='choice_4_52_0' onchange='gformToggleRadioOther( this )'  tabindex='43'  \/>\n\t\t\t\t\t<label for='choice_4_52_0' id='label_4_52_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_52_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='Non'  id='choice_4_52_1' onchange='gformToggleRadioOther( this )'  tabindex='44'  \/>\n\t\t\t\t\t<label for='choice_4_52_1' id='label_4_52_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_53\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_53'><span class='gform-field-label__text'>Si oui, utilisez-vous actuellement un appareil CPAP ou un autre traitement\u202f?<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_53' id='input_4_53' class='textarea small' tabindex='45'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_54\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Avez-vous des ant\u00e9c\u00e9dents personnels de thromboembolie veineuse (caillots sanguins)\u202f?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_54'>\n\t\t\t<div class='gchoice gchoice_4_54_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Oui'  id='choice_4_54_0' onchange='gformToggleRadioOther( this )'  tabindex='46'  \/>\n\t\t\t\t\t<label for='choice_4_54_0' id='label_4_54_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_54_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Non'  id='choice_4_54_1' onchange='gformToggleRadioOther( this )'  tabindex='47'  \/>\n\t\t\t\t\t<label for='choice_4_54_1' id='label_4_54_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_55\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Avez-vous d\u00e9j\u00e0 re\u00e7u un diagnostic de cancer de la prostate, du sein ou d\u2019un autre cancer sensible aux hormones\u202f?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_55'>\n\t\t\t<div class='gchoice gchoice_4_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Oui'  id='choice_4_55_0' onchange='gformToggleRadioOther( this )'  tabindex='48'  \/>\n\t\t\t\t\t<label for='choice_4_55_0' id='label_4_55_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Non'  id='choice_4_55_1' onchange='gformToggleRadioOther( this )'  tabindex='49'  \/>\n\t\t\t\t\t<label for='choice_4_55_1' id='label_4_55_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_48\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_48'><span class='gform-field-label__text'>Veuillez \u00e9num\u00e9rer vos interventions chirurgicales ant\u00e9rieures (le cas \u00e9ch\u00e9ant)<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_48' id='input_4_48' class='textarea small' tabindex='50'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Prenez-vous des m\u00e9dicaments ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_20'>\n\t\t\t<div class='gchoice gchoice_4_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Oui'  id='choice_4_20_0' onchange='gformToggleRadioOther( this )'  tabindex='51'  \/>\n\t\t\t\t\t<label for='choice_4_20_0' id='label_4_20_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Non'  id='choice_4_20_1' onchange='gformToggleRadioOther( this )'  tabindex='52'  \/>\n\t\t\t\t\t<label for='choice_4_20_1' id='label_4_20_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_17\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_17'><span class='gform-field-label__text'>Si oui, veuillez pr\u00e9ciser<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_17' id='input_4_17' class='textarea small' tabindex='53'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_18\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Avez-vous des allergies aux m\u00e9dicaments ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_18'>\n\t\t\t<div class='gchoice gchoice_4_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Oui'  id='choice_4_18_0' onchange='gformToggleRadioOther( this )'  tabindex='54'  \/>\n\t\t\t\t\t<label for='choice_4_18_0' id='label_4_18_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Non'  id='choice_4_18_1' onchange='gformToggleRadioOther( this )'  tabindex='55'  \/>\n\t\t\t\t\t<label for='choice_4_18_1' id='label_4_18_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_19\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_19'><span class='gform-field-label__text'>Si oui, veuillez pr\u00e9ciser<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_19' id='input_4_19' class='textarea small' tabindex='56'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_56\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Avez-vous des allergies alimentaires\u202f?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_56'>\n\t\t\t<div class='gchoice gchoice_4_56_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='Oui'  id='choice_4_56_0' onchange='gformToggleRadioOther( this )'  tabindex='57'  \/>\n\t\t\t\t\t<label for='choice_4_56_0' id='label_4_56_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_56_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='Non'  id='choice_4_56_1' onchange='gformToggleRadioOther( this )'  tabindex='58'  \/>\n\t\t\t\t\t<label for='choice_4_56_1' id='label_4_56_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_57\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_57'><span class='gform-field-label__text'>Si oui, veuillez pr\u00e9ciser<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_57' id='input_4_57' class='textarea small' tabindex='59'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_45\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Combien de boissons alcoolis\u00e9es consommez-vous par semaine ?<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_45'><div class='gchoice gchoice_4_45_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.1' type='checkbox'  value='Aucune'  id='choice_4_45_1' tabindex='60'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_45_1' id='label_4_45_1' class='gform-field-label gform-field-label--type-inline'>Aucune<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_45_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.2' type='checkbox'  value='1-4'  id='choice_4_45_2' tabindex='61'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_45_2' id='label_4_45_2' class='gform-field-label gform-field-label--type-inline'>1-4<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_45_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.3' type='checkbox'  value='5 ou plus'  id='choice_4_45_3' tabindex='62'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_45_3' id='label_4_45_3' class='gform-field-label gform-field-label--type-inline'>5 ou plus<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Est-ce que vous fumez des cigarettes ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_21'>\n\t\t\t<div class='gchoice gchoice_4_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Oui'  id='choice_4_21_0' onchange='gformToggleRadioOther( this )'  tabindex='63'  \/>\n\t\t\t\t\t<label for='choice_4_21_0' id='label_4_21_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Non'  id='choice_4_21_1' onchange='gformToggleRadioOther( this )'  tabindex='64'  \/>\n\t\t\t\t\t<label for='choice_4_21_1' id='label_4_21_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_65\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Utilisez-vous des drogues illicites (cannabis, opio\u00efdes, etc.)\u202f?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_65'>\n\t\t\t<div class='gchoice gchoice_4_65_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='Oui'  id='choice_4_65_0' onchange='gformToggleRadioOther( this )'  tabindex='65'  \/>\n\t\t\t\t\t<label for='choice_4_65_0' id='label_4_65_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_65_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='Non'  id='choice_4_65_1' onchange='gformToggleRadioOther( this )'  tabindex='66'  \/>\n\t\t\t\t\t<label for='choice_4_65_1' id='label_4_65_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_66\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_66'><span class='gform-field-label__text'>Si oui, veuillez pr\u00e9ciser<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_66' id='input_4_66' class='textarea small' tabindex='67'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_49\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Avez-vous le d\u00e9sir de pr\u00e9server votre fertilit\u00e9 (pr\u00e9voyez-vous avoir des enfants \u00e0 l\u2019avenir) ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_49'>\n\t\t\t<div class='gchoice gchoice_4_49_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Oui'  id='choice_4_49_0' onchange='gformToggleRadioOther( this )'  tabindex='68'  \/>\n\t\t\t\t\t<label for='choice_4_49_0' id='label_4_49_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_49_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Non'  id='choice_4_49_1' onchange='gformToggleRadioOther( this )'  tabindex='69'  \/>\n\t\t\t\t\t<label for='choice_4_49_1' id='label_4_49_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_44\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00cates-vous un patient de Steinberg Urologie ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_44'>\n\t\t\t<div class='gchoice gchoice_4_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Oui'  id='choice_4_44_0' onchange='gformToggleRadioOther( this )'  tabindex='70'  \/>\n\t\t\t\t\t<label for='choice_4_44_0' id='label_4_44_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Non'  id='choice_4_44_1' onchange='gformToggleRadioOther( this )'  tabindex='71'  \/>\n\t\t\t\t\t<label for='choice_4_44_1' id='label_4_44_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_43\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">VOS INFORMATIONS PERSONNELLES<\/h3><\/div><fieldset id=\"field_4_24\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_4_24'>\n                            \n                            <span id='input_4_24_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_24.3' id='input_4_24_3' value='' tabindex='73'  aria-required='true'     \/>\n                                                    <label for='input_4_24_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom *<\/label>\n                                                <\/span>\n                            \n                            <span id='input_4_24_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_24.6' id='input_4_24_6' value='' tabindex='75'  aria-required='true'     \/>\n                                                    <label for='input_4_24_6' class='gform-field-label gform-field-label--type-sub '>Nom de famille *<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_4_25\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_25'><span class='gform-field-label__text'>Date de naissance<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='aaaa-mm-jj'\n\t\t\t\t\tid='input_4_25'\n\t\t\t\t\tclass='datepicker gform-datepicker ymd_dash datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_25'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\ttabindex='77' \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"9999-99-99\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_4_25' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_4_25' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_4_25' aria-label='Date de naissance: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_4_26\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-two-thirds field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_26'><span class='gform-field-label__text'>Adresse<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_4_26' type='text' value='' class='large'   tabindex='78'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_27\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_27'><span class='gform-field-label__text'>T\u00e9l\u00e9phone<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_27' id='input_4_27' type='tel' value='' class='large' tabindex='79'  aria-required=\"true\" aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_4_28\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_28'><span class='gform-field-label__text'>Courriel<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_28' id='input_4_28' type='email' value='' class='large' tabindex='80'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_4_29\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_29'><span class='gform-field-label__text'>Fournir des informations suppl\u00e9mentaires, si necessaire<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_29' id='input_4_29' class='textarea small' tabindex='81'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_30\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Consent<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_30'><div class='gchoice gchoice_4_30_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.1' type='checkbox'  value='Je conviens que les informations m\u00e9dicales ci-dessus sont factuelles au meilleur de ma connaissance.'  id='choice_4_30_1' tabindex='82'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_30_1' id='label_4_30_1' class='gform-field-label gform-field-label--type-inline'>Je conviens que les informations m\u00e9dicales ci-dessus sont factuelles au meilleur de ma connaissance.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_30_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.2' type='checkbox'  value='Je comprends qu&#039;en cas d&#039;aggravation des sympt\u00f4mes ou de r\u00e9action allergique aux m\u00e9dicaments, je consulterai imm\u00e9diatement un m\u00e9decin.'  id='choice_4_30_2' tabindex='83'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_30_2' id='label_4_30_2' class='gform-field-label gform-field-label--type-inline'>Je comprends qu'en cas d'aggravation des sympt\u00f4mes ou de r\u00e9action allergique aux m\u00e9dicaments, je consulterai imm\u00e9diatement un m\u00e9decin.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_30_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.3' type='checkbox'  value='Je comprends que le m\u00e9decin impliqu\u00e9 dans ce dossier n&#039;est pas associ\u00e9 \u00e0 la RAMQ.'  id='choice_4_30_3' tabindex='84'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_30_3' id='label_4_30_3' class='gform-field-label gform-field-label--type-inline'>Je comprends que le m\u00e9decin impliqu\u00e9 dans ce dossier n'est pas associ\u00e9 \u00e0 la RAMQ.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_4' class='gform_button button gform-button--width-full' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' tabindex='85'>Confirmer<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_4' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_4' id='gform_theme_4' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_4' id='gform_style_settings_4' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_4' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='4' \/>\n            \n            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