{"id":32856,"date":"2026-05-26T13:42:05","date_gmt":"2026-05-26T10:42:05","guid":{"rendered":"https:\/\/kiropraktik.ee\/kusimustik\/"},"modified":"2026-05-26T14:11:17","modified_gmt":"2026-05-26T11:11:17","slug":"questionaire","status":"publish","type":"page","link":"https:\/\/kiropraktik.ee\/ru\/questionaire\/","title":{"rendered":"Questionaire"},"content":{"rendered":"\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f32845-o1\" lang=\"et\" dir=\"ltr\" data-wpcf7-id=\"32845\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/ru\/wp-json\/wp\/v2\/pages\/32856#wpcf7-f32845-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Kontaktivorm\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"32845\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.7\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"et\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f32845-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<div class=\"fsc-questionnaire\">\n<div class=\"fsc-wizard\" data-storage-key=\"fsc-questionnaire-progress\">\n\n  <div class=\"fsc-progress\">\n    <button type=\"button\" class=\"fsc-progress-step is-active\" data-step-target=\"0\"><span>1<\/span> Personal<\/button>\n    <button type=\"button\" class=\"fsc-progress-step\" data-step-target=\"1\"><span>2<\/span> Contact<\/button>\n    <button type=\"button\" class=\"fsc-progress-step\" data-step-target=\"2\"><span>3<\/span> Doctor<\/button>\n    <button type=\"button\" class=\"fsc-progress-step\" data-step-target=\"3\"><span>4<\/span> Condition<\/button>\n    <button type=\"button\" class=\"fsc-progress-step\" data-step-target=\"4\"><span>5<\/span> Diagnosis<\/button>\n    <button type=\"button\" class=\"fsc-progress-step\" data-step-target=\"5\"><span>6<\/span> SPADI<\/button>\n    <button type=\"button\" class=\"fsc-progress-step\" data-step-target=\"6\"><span>7<\/span> Files<\/button>\n  <\/div>\n\n  <div class=\"fsc-step is-active\" data-step=\"0\">\n    <div class=\"fsc-form-section\">\n      <h2>Personal Information<\/h2>\n\n      <div class=\"fsc-grid cols-2\">\n        <div class=\"fsc-field\">\n          <label>Your Full Name <span>*<\/span><\/label>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Enter your full name\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span>\n        <\/div>\n\n        <div class=\"fsc-field\">\n          <label>Sex <span>*<\/span><\/label>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"sex\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"sex\"><option value=\"\">&#8212;Palun vali valik&#8212;<\/option><option value=\"Female\">Female<\/option><option value=\"Male\">Male<\/option><\/select><\/span>\n        <\/div>\n\n        <div class=\"fsc-field\">\n          <label>Height <span>*<\/span><\/label>\n          <div class=\"fsc-input-unit\"><span class=\"wpcf7-form-control-wrap\" data-name=\"height\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" max=\"300\" aria-required=\"true\" aria-invalid=\"false\" value=\"180\" type=\"number\" name=\"height\" \/><\/span><span>cm<\/span><\/div>\n        <\/div>\n\n        <div class=\"fsc-field\">\n          <label>Weight <span>*<\/span><\/label>\n          <div class=\"fsc-input-unit\"><span class=\"wpcf7-form-control-wrap\" data-name=\"weight\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" max=\"300\" aria-required=\"true\" aria-invalid=\"false\" value=\"65\" type=\"number\" name=\"weight\" \/><\/span><span>kg<\/span><\/div>\n        <\/div>\n      <\/div>\n\n      <div class=\"fsc-field\">\n        <label>Date of Birth <span>*<\/span><\/label>\n        <div class=\"fsc-date-grid\">\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"Birth-date\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"Birth-date\"><option value=\"\">&#8212;Palun vali valik&#8212;<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10\">10<\/option><option value=\"11\">11<\/option><option value=\"12\">12<\/option><option value=\"13\">13<\/option><option value=\"14\">14<\/option><option value=\"15\">15<\/option><option value=\"16\">16<\/option><option value=\"17\">17<\/option><option value=\"18\">18<\/option><option value=\"19\">19<\/option><option value=\"20\">20<\/option><option value=\"21\">21<\/option><option value=\"22\">22<\/option><option value=\"23\">23<\/option><option value=\"24\">24<\/option><option value=\"25\">25<\/option><option value=\"26\">26<\/option><option value=\"27\">27<\/option><option value=\"28\">28<\/option><option value=\"29\">29<\/option><option value=\"30\">30<\/option><option value=\"31\">31<\/option><\/select><\/span>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"Birth-month\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"Birth-month\"><option value=\"\">&#8212;Palun vali valik&#8212;<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10\">10<\/option><option value=\"11\">11<\/option><option value=\"12\">12<\/option><\/select><\/span>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"birth-year\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" min=\"1940\" max=\"2020\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Year\" value=\"\" type=\"number\" name=\"birth-year\" \/><\/span>\n        <\/div>\n      <\/div>\n\n      <div class=\"fsc-field\">\n        <label>How did you first hear about us? <span>*<\/span><\/label>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"How-found\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"How-found\"><option value=\"\">&#8212;Palun vali valik&#8212;<\/option><option value=\"Friend recommended\">Friend recommended<\/option><option value=\"Youtube\">Youtube<\/option><option value=\"Facebook\">Facebook<\/option><option value=\"Google search\">Google search<\/option><option value=\"Searched on Internet\">Searched on Internet<\/option><option value=\"Doctor, therapist recommended\">Doctor, therapist recommended<\/option><option value=\"TV\/radio show\">TV\/radio show<\/option><option value=\"An advertisement (Internet, TV, radio, magazine, street)\">An advertisement (Internet, TV, radio, magazine, street)<\/option><option value=\"Other\">Other<\/option><\/select><\/span>\n      <\/div>\n    <\/div>\n  <\/div>\n\n  <div class=\"fsc-step\" data-step=\"1\">\n    <div class=\"fsc-form-section\">\n      <h2>Your Contact Details<\/h2>\n\n      <div class=\"fsc-grid cols-2\">\n        <div class=\"fsc-field\">\n          <label>Email <span>*<\/span><\/label>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"your@email.com\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span>\n        <\/div>\n\n        <div class=\"fsc-field\">\n          <label>Phone <span>*<\/span><\/label>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"tel-23\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Phone number\" value=\"\" type=\"tel\" name=\"tel-23\" \/><\/span>\n        <\/div>\n\n        <div class=\"fsc-field\">\n          <label>Address <span>*<\/span><\/label>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"text-155\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Street, City, State\" value=\"\" type=\"text\" name=\"text-155\" \/><\/span>\n        <\/div>\n\n        <div class=\"fsc-field\">\n          <label>ZIP \/ Postal Code <span>*<\/span><\/label>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"zipcode\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Zip Code\" value=\"\" type=\"text\" name=\"zipcode\" \/><\/span>\n        <\/div>\n      <\/div>\n\n      <div class=\"fsc-field\">\n        <label>Country <span>*<\/span><\/label>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"coutrylist\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"coutrylist\"><option value=\"\">&#8212;Palun vali valik&#8212;<\/option><option value=\"Afghanistan\">Afghanistan<\/option><option value=\"Akrotiri\">Akrotiri<\/option><option value=\"Albania\">Albania<\/option><option value=\"Algeria\">Algeria<\/option><option value=\"American Samoa\">American Samoa<\/option><option value=\"Andorra\">Andorra<\/option><option value=\"Angola\">Angola<\/option><option value=\"Anguilla\">Anguilla<\/option><option value=\"Antarctica\">Antarctica<\/option><option value=\"Antigua and Barbuda\">Antigua and Barbuda<\/option><option value=\"Argentina\">Argentina<\/option><option value=\"Armenia\">Armenia<\/option><option value=\"Aruba\">Aruba<\/option><option value=\"Ashmore and Cartier Islands\">Ashmore and Cartier Islands<\/option><option value=\"Australia\">Australia<\/option><option value=\"Austria\">Austria<\/option><option value=\"Azerbaijan\">Azerbaijan<\/option><option value=\"Bahamas\">Bahamas<\/option><option value=\"Bahrain\">Bahrain<\/option><option value=\"Bangladesh\">Bangladesh<\/option><option value=\"Barbados\">Barbados<\/option><option value=\"Bassas da India\">Bassas da India<\/option><option value=\"Belarus\">Belarus<\/option><option value=\"Belgium\">Belgium<\/option><option value=\"Belize\">Belize<\/option><option value=\"Benin\">Benin<\/option><option value=\"Bermuda\">Bermuda<\/option><option value=\"Bhutan\">Bhutan<\/option><option value=\"Bolivia\">Bolivia<\/option><option value=\"Bosnia and Herzegovina\">Bosnia and Herzegovina<\/option><option value=\"Botswana\">Botswana<\/option><option value=\"Bouvet Island\">Bouvet Island<\/option><option value=\"Brazil\">Brazil<\/option><option value=\"British Indian Ocean Territory\">British Indian Ocean Territory<\/option><option value=\"British Virgin Islands\">British Virgin Islands<\/option><option value=\"Brunei\">Brunei<\/option><option value=\"Bulgaria\">Bulgaria<\/option><option value=\"Burkina Faso\">Burkina Faso<\/option><option value=\"Burma\">Burma<\/option><option value=\"Burundi\">Burundi<\/option><option value=\"Cambodia\">Cambodia<\/option><option value=\"Cameroon\">Cameroon<\/option><option value=\"Canada\">Canada<\/option><option value=\"Cape Verde\">Cape Verde<\/option><option value=\"Cayman Islands\">Cayman Islands<\/option><option value=\"Central African Republic\">Central African Republic<\/option><option value=\"Chad\">Chad<\/option><option value=\"Chile\">Chile<\/option><option value=\"China\">China<\/option><option value=\"Christmas Island\">Christmas Island<\/option><option value=\"Clipperton Island\">Clipperton Island<\/option><option value=\"Cocos (Keeling) Islands\">Cocos (Keeling) Islands<\/option><option value=\"Colombia\">Colombia<\/option><option value=\"Comoros\">Comoros<\/option><option value=\"Congo, Democratic Republic of the\">Congo, Democratic Republic of the<\/option><option value=\"Congo, Republic of the\">Congo, Republic of the<\/option><option value=\"Cook Islands\">Cook Islands<\/option><option value=\"Coral Sea Islands\">Coral Sea Islands<\/option><option value=\"Costa Rica\">Costa Rica<\/option><option value=\"Cote d&#039;Ivoire\">Cote d&#039;Ivoire<\/option><option value=\"Croatia\">Croatia<\/option><option value=\"Cuba\">Cuba<\/option><option value=\"Cyprus\">Cyprus<\/option><option value=\"Czech Republic\">Czech Republic<\/option><option value=\"Denmark\">Denmark<\/option><option value=\"Dhekelia\">Dhekelia<\/option><option value=\"Djibouti\">Djibouti<\/option><option value=\"Dominica\">Dominica<\/option><option value=\"Dominican Republic\">Dominican Republic<\/option><option value=\"Ecuador\">Ecuador<\/option><option value=\"Egypt\">Egypt<\/option><option value=\"El Salvador\">El Salvador<\/option><option value=\"Equatorial Guinea\">Equatorial Guinea<\/option><option value=\"Eritrea\">Eritrea<\/option><option value=\"Estonia\">Estonia<\/option><option value=\"Ethiopia\">Ethiopia<\/option><option value=\"Europa Island\">Europa Island<\/option><option value=\"Falkland Islands (Islas Malvinas)\">Falkland Islands (Islas Malvinas)<\/option><option value=\"Faroe Islands\">Faroe Islands<\/option><option value=\"Fiji\">Fiji<\/option><option value=\"Finland\">Finland<\/option><option value=\"France\">France<\/option><option value=\"French Guiana\">French Guiana<\/option><option value=\"French Polynesia\">French Polynesia<\/option><option value=\"French Southern and Antarctic Lands\">French Southern and Antarctic Lands<\/option><option value=\"Gabon\">Gabon<\/option><option value=\"Gambia\">Gambia<\/option><option value=\"Gaza Strip\">Gaza Strip<\/option><option value=\"Georgia\">Georgia<\/option><option value=\"Germany\">Germany<\/option><option value=\"Ghana\">Ghana<\/option><option value=\"Gibraltar\">Gibraltar<\/option><option value=\"Glorioso Islands\">Glorioso Islands<\/option><option value=\"Greece\">Greece<\/option><option value=\"Greenland\">Greenland<\/option><option value=\"Grenada\">Grenada<\/option><option value=\"Guadeloupe\">Guadeloupe<\/option><option value=\"Guam\">Guam<\/option><option value=\"Guatemala\">Guatemala<\/option><option value=\"Guernsey\">Guernsey<\/option><option value=\"Guinea\">Guinea<\/option><option value=\"Guinea-Bissau\">Guinea-Bissau<\/option><option value=\"Guyana\">Guyana<\/option><option value=\"Haiti\">Haiti<\/option><option value=\"Heard Island and McDonald Islands\">Heard Island and McDonald Islands<\/option><option value=\"Holy See (Vatican City)\">Holy See (Vatican City)<\/option><option value=\"Honduras\">Honduras<\/option><option value=\"Hong Kong\">Hong Kong<\/option><option value=\"Hungary\">Hungary<\/option><option value=\"Iceland\">Iceland<\/option><option value=\"India\">India<\/option><option value=\"Indonesia\">Indonesia<\/option><option value=\"Iran\">Iran<\/option><option value=\"Iraq\">Iraq<\/option><option value=\"Ireland\">Ireland<\/option><option value=\"Isle of Man\">Isle of Man<\/option><option value=\"Israel\">Israel<\/option><option value=\"Italy\">Italy<\/option><option value=\"Jamaica\">Jamaica<\/option><option value=\"Jan Mayen\">Jan Mayen<\/option><option value=\"Japan\">Japan<\/option><option value=\"Jersey\">Jersey<\/option><option value=\"Jordan\">Jordan<\/option><option value=\"Juan de Nova Island\">Juan de Nova Island<\/option><option value=\"Kazakhstan\">Kazakhstan<\/option><option value=\"Kenya\">Kenya<\/option><option value=\"Kiribati\">Kiribati<\/option><option value=\"Korea, North\">Korea, North<\/option><option value=\"Korea, South\">Korea, South<\/option><option value=\"Kuwait\">Kuwait<\/option><option value=\"Kyrgyzstan\">Kyrgyzstan<\/option><option value=\"Laos\">Laos<\/option><option value=\"Latvia\">Latvia<\/option><option value=\"Lebanon\">Lebanon<\/option><option value=\"Lesotho\">Lesotho<\/option><option value=\"Liberia\">Liberia<\/option><option value=\"Libya\">Libya<\/option><option value=\"Liechtenstein\">Liechtenstein<\/option><option value=\"Lithuania\">Lithuania<\/option><option value=\"Luxembourg\">Luxembourg<\/option><option value=\"Macau\">Macau<\/option><option value=\"Macedonia\">Macedonia<\/option><option value=\"Madagascar\">Madagascar<\/option><option value=\"Malawi\">Malawi<\/option><option value=\"Malaysia\">Malaysia<\/option><option value=\"Maldives\">Maldives<\/option><option value=\"Mali\">Mali<\/option><option value=\"Malta\">Malta<\/option><option value=\"Marshall Islands\">Marshall Islands<\/option><option value=\"Martinique\">Martinique<\/option><option value=\"Mauritania\">Mauritania<\/option><option value=\"Mauritius\">Mauritius<\/option><option value=\"Mayotte\">Mayotte<\/option><option value=\"Mexico\">Mexico<\/option><option value=\"Micronesia, Federated States of\">Micronesia, Federated States of<\/option><option value=\"Moldova\">Moldova<\/option><option value=\"Monaco\">Monaco<\/option><option value=\"Mongolia\">Mongolia<\/option><option value=\"Montserrat\">Montserrat<\/option><option value=\"Morocco\">Morocco<\/option><option value=\"Mozambique\">Mozambique<\/option><option value=\"Namibia\">Namibia<\/option><option value=\"Nauru\">Nauru<\/option><option value=\"Navassa Island\">Navassa Island<\/option><option value=\"Nepal\">Nepal<\/option><option value=\"Netherlands\">Netherlands<\/option><option value=\"Netherlands Antilles\">Netherlands Antilles<\/option><option value=\"New Caledonia\">New Caledonia<\/option><option value=\"New Zealand\">New Zealand<\/option><option value=\"Nicaragua\">Nicaragua<\/option><option value=\"Niger\">Niger<\/option><option value=\"Nigeria\">Nigeria<\/option><option value=\"Niue\">Niue<\/option><option value=\"Norfolk Island\">Norfolk Island<\/option><option value=\"Northern Mariana Islands\">Northern Mariana Islands<\/option><option value=\"Norway\">Norway<\/option><option value=\"Oman\">Oman<\/option><option value=\"Pakistan\">Pakistan<\/option><option value=\"Palau\">Palau<\/option><option value=\"Panama\">Panama<\/option><option value=\"Papua New Guinea\">Papua New Guinea<\/option><option value=\"Paracel Islands\">Paracel Islands<\/option><option value=\"Paraguay\">Paraguay<\/option><option value=\"Peru\">Peru<\/option><option value=\"Philippines\">Philippines<\/option><option value=\"Pitcairn Islands\">Pitcairn Islands<\/option><option value=\"Poland\">Poland<\/option><option value=\"Portugal\">Portugal<\/option><option value=\"Puerto Rico\">Puerto Rico<\/option><option value=\"Qatar\">Qatar<\/option><option value=\"Reunion\">Reunion<\/option><option value=\"Romania\">Romania<\/option><option value=\"Russia\">Russia<\/option><option value=\"Rwanda\">Rwanda<\/option><option value=\"Saint Helena\">Saint Helena<\/option><option value=\"Saint Kitts and Nevis\">Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\">Saint Lucia<\/option><option value=\"Saint Pierre and Miquelon\">Saint Pierre and Miquelon<\/option><option value=\"Saint Vincent and the Grenadines\">Saint Vincent and the Grenadines<\/option><option value=\"Samoa\">Samoa<\/option><option value=\"San Marino\">San Marino<\/option><option value=\"Sao Tome and Principe\">Sao Tome and Principe<\/option><option value=\"Saudi Arabia\">Saudi Arabia<\/option><option value=\"Senegal\">Senegal<\/option><option value=\"Serbia and Montenegro\">Serbia and Montenegro<\/option><option value=\"Seychelles\">Seychelles<\/option><option value=\"Sierra Leone\">Sierra Leone<\/option><option value=\"Singapore\">Singapore<\/option><option value=\"Slovakia\">Slovakia<\/option><option value=\"Slovenia\">Slovenia<\/option><option value=\"Solomon Islands\">Solomon Islands<\/option><option value=\"Somalia\">Somalia<\/option><option value=\"South Africa\">South Africa<\/option><option value=\"S. Georgia &amp; S. Sandwich Islands\">S. Georgia &amp; S. Sandwich Islands<\/option><option value=\"Spain\">Spain<\/option><option value=\"Spratly Islands\">Spratly Islands<\/option><option value=\"Sri Lanka\">Sri Lanka<\/option><option value=\"Sudan\">Sudan<\/option><option value=\"Suriname\">Suriname<\/option><option value=\"Svalbard\">Svalbard<\/option><option value=\"Swaziland\">Swaziland<\/option><option value=\"Sweden\">Sweden<\/option><option value=\"Switzerland\">Switzerland<\/option><option value=\"Syria\">Syria<\/option><option value=\"Taiwan\">Taiwan<\/option><option value=\"Tajikistan\">Tajikistan<\/option><option value=\"Tanzania\">Tanzania<\/option><option value=\"Thailand\">Thailand<\/option><option value=\"Timor-Leste\">Timor-Leste<\/option><option value=\"Togo\">Togo<\/option><option value=\"Tokelau\">Tokelau<\/option><option value=\"Tonga\">Tonga<\/option><option value=\"Trinidad and Tobago\">Trinidad and Tobago<\/option><option value=\"Tromelin Island\">Tromelin Island<\/option><option value=\"Tunisia\">Tunisia<\/option><option value=\"Turkey\">Turkey<\/option><option value=\"Turkmenistan\">Turkmenistan<\/option><option value=\"Turks and Caicos Islands\">Turks and Caicos Islands<\/option><option value=\"Tuvalu\">Tuvalu<\/option><option value=\"Uganda\">Uganda<\/option><option value=\"Ukraine\">Ukraine<\/option><option value=\"United Arab Emirates\">United Arab Emirates<\/option><option value=\"United Kingdom\">United Kingdom<\/option><option value=\"United States\">United States<\/option><option value=\"Uruguay\">Uruguay<\/option><option value=\"Uzbekistan\">Uzbekistan<\/option><option value=\"Vanuatu\">Vanuatu<\/option><option value=\"Venezuela\">Venezuela<\/option><option value=\"Vietnam\">Vietnam<\/option><option value=\"Virgin Islands\">Virgin Islands<\/option><option value=\"Wake Island\">Wake Island<\/option><option value=\"Wallis and Futuna\">Wallis and Futuna<\/option><option value=\"West Bank\">West Bank<\/option><option value=\"Western Sahara\">Western Sahara<\/option><option value=\"Yemen\">Yemen<\/option><option value=\"Zambia\">Zambia<\/option><option value=\"Zimbabwe\">Zimbabwe<\/option><\/select><\/span>\n      <\/div>\n\n      <div class=\"fsc-grid cols-2\">\n        <div class=\"fsc-field\">\n          <label>Occupation <span>*<\/span><\/label>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"occupation\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Occupation\" value=\"\" type=\"text\" name=\"occupation\" \/><\/span>\n        <\/div>\n\n        <div class=\"fsc-field\">\n          <label>Job Description<\/label>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"jobdescription\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Job description\" name=\"jobdescription\"><\/textarea><\/span>\n        <\/div>\n      <\/div>\n    <\/div>\n  <\/div>\n\n  <div class=\"fsc-step\" data-step=\"2\">\n    <div class=\"fsc-form-section\">\n      <h2>Medical Doctor<\/h2>\n\n      <div class=\"fsc-grid cols-2\">\n        <div class=\"fsc-field\"><label>Name of your Medical Doctor <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"doctor_name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Name or -\" value=\"\" type=\"text\" name=\"doctor_name\" \/><\/span><\/div>\n        <div class=\"fsc-field\"><label>Specialty<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"doctor_spec\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"doctor_spec\"><option value=\"\">&#8212;Palun vali valik&#8212;<\/option><option value=\"Medical Doctor\">Medical Doctor<\/option><option value=\"General Practitioner\">General Practitioner<\/option><option value=\"Osteopath\">Osteopath<\/option><option value=\"Chiropractor\">Chiropractor<\/option><option value=\"Physiotherapist\">Physiotherapist<\/option><option value=\"Hospitalist\">Hospitalist<\/option><option value=\"Surgeon\">Surgeon<\/option><option value=\"Cardiologist\">Cardiologist<\/option><option value=\"Dermatologist\">Dermatologist<\/option><option value=\"Endocrinologist\">Endocrinologist<\/option><option value=\"Gastroenterologist\">Gastroenterologist<\/option><option value=\"Obstetrician\">Obstetrician<\/option><option value=\"Otolaryngologist\">Otolaryngologist<\/option><option value=\"Massage Therapist\">Massage Therapist<\/option><option value=\"Certified Trainer\">Certified Trainer<\/option><option value=\"Other\">Other<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>Contact Phone<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"doctor_phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Contact Phone\" value=\"\" type=\"text\" name=\"doctor_phone\" \/><\/span><\/div>\n        <div class=\"fsc-field\"><label>Contact Email<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"doctor_mail\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Contact Email\" value=\"\" type=\"text\" name=\"doctor_mail\" \/><\/span><\/div>\n      <\/div>\n\n      <h3>Other doctors or therapists you have seen for this problem<\/h3>\n\n      <div class=\"fsc-grid cols-2\">\n        <div class=\"fsc-field\"><label>Doctor \/ Therapist Name<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"doctor_name1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Doctor&#039;s Name\" value=\"\" type=\"text\" name=\"doctor_name1\" \/><\/span><\/div>\n        <div class=\"fsc-field\"><label>Specialty<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"doctor_spec1\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"doctor_spec1\"><option value=\"\">&#8212;Palun vali valik&#8212;<\/option><option value=\"Medical Doctor\">Medical Doctor<\/option><option value=\"General Practitioner\">General Practitioner<\/option><option value=\"Osteopath\">Osteopath<\/option><option value=\"Chiropractor\">Chiropractor<\/option><option value=\"Physiotherapist\">Physiotherapist<\/option><option value=\"Hospitalist\">Hospitalist<\/option><option value=\"Surgeon\">Surgeon<\/option><option value=\"Cardiologist\">Cardiologist<\/option><option value=\"Dermatologist\">Dermatologist<\/option><option value=\"Endocrinologist\">Endocrinologist<\/option><option value=\"Gastroenterologist\">Gastroenterologist<\/option><option value=\"Obstetrician\">Obstetrician<\/option><option value=\"Otolaryngologist\">Otolaryngologist<\/option><option value=\"Massage Therapist\">Massage Therapist<\/option><option value=\"Certified Trainer\">Certified Trainer<\/option><option value=\"Other\">Other<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>Phone<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"doctor_phone1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Phone\" value=\"\" type=\"text\" name=\"doctor_phone1\" \/><\/span><\/div>\n        <div class=\"fsc-field\"><label>Email<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"doctor_mail1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Email\" value=\"\" type=\"text\" name=\"doctor_mail1\" \/><\/span><\/div>\n\n        <div class=\"fsc-field\"><label>Doctor \/ Therapist Name<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"doctor_name2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Doctor&#039;s Name\" value=\"\" type=\"text\" name=\"doctor_name2\" \/><\/span><\/div>\n        <div class=\"fsc-field\"><label>Specialty<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"doctor_spec2\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"doctor_spec2\"><option value=\"\">&#8212;Palun vali valik&#8212;<\/option><option value=\"Medical Doctor\">Medical Doctor<\/option><option value=\"General Practitioner\">General Practitioner<\/option><option value=\"Osteopath\">Osteopath<\/option><option value=\"Chiropractor\">Chiropractor<\/option><option value=\"Physiotherapist\">Physiotherapist<\/option><option value=\"Hospitalist\">Hospitalist<\/option><option value=\"Surgeon\">Surgeon<\/option><option value=\"Cardiologist\">Cardiologist<\/option><option value=\"Dermatologist\">Dermatologist<\/option><option value=\"Endocrinologist\">Endocrinologist<\/option><option value=\"Gastroenterologist\">Gastroenterologist<\/option><option value=\"Obstetrician\">Obstetrician<\/option><option value=\"Otolaryngologist\">Otolaryngologist<\/option><option value=\"Massage Therapist\">Massage Therapist<\/option><option value=\"Certified Trainer\">Certified Trainer<\/option><option value=\"Other\">Other<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>Phone<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"doctor_phone2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Phone\" value=\"\" type=\"text\" name=\"doctor_phone2\" \/><\/span><\/div>\n        <div class=\"fsc-field\"><label>Email<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"doctor_mail2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Email\" value=\"\" type=\"text\" name=\"doctor_mail2\" \/><\/span><\/div>\n      <\/div>\n    <\/div>\n  <\/div>\n\n  <div class=\"fsc-step\" data-step=\"3\">\n    <div class=\"fsc-form-section\">\n      <h2>Your Condition<\/h2>\n\n      <p class=\"fsc-help-text\">Please answer the questions below so that we can better understand your condition and advise you on the best next steps.<\/p>\n      <div class=\"fsc-notice\">Fields marked with * are required.<\/div>\n\n      <h3>Date of Onset<\/h3>\n      <div class=\"fsc-field\"><label>When were you first diagnosed with frozen shoulder? <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"Date-onset\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"31.01.2005\" value=\"\" type=\"text\" name=\"Date-onset\" \/><\/span><\/div>\n\n      <h3>Current Situation<\/h3>\n      <div class=\"fsc-grid cols-2\">\n        <div class=\"fsc-field\"><label>Is it getting worse? <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"currdiag01\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"currdiag01\"><option value=\"\">&#8212;Palun vali valik&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>Have you lost work time? <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"currdiag02\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"currdiag02\"><option value=\"\">&#8212;Palun vali valik&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>Does it interfere with sleep? <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"currdiag03\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"currdiag03\"><option value=\"\">&#8212;Palun vali valik&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>Does it interfere with work? <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"currdiag04\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"currdiag04\"><option value=\"\">&#8212;Palun vali valik&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>Does it interfere with daily routine? <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"currdiag05\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"currdiag05\"><option value=\"\">&#8212;Palun vali valik&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>Was it result of an accident? <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"currdiag06\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"currdiag06\"><option value=\"\">&#8212;Palun vali valik&#8212;<\/option><option value=\"Yes, car accident\">Yes, car accident<\/option><option value=\"Yes, on the job\">Yes, on the job<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/div>\n      <\/div>\n\n      <div class=\"fsc-field\"><label>If it was result of an accident, describe the circumstances<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"your-message01\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"-\" name=\"your-message01\"><\/textarea><\/span><\/div>\n\n      <h3>Movability<\/h3>\n      <p class=\"fsc-help-text\">Percentage of shoulder movability. Total: 0\/100, numbers only.<\/p>\n\n      <h4>Right Side<\/h4>\n      <div class=\"fsc-grid cols-3\">\n        <div class=\"fsc-field\"><label>Forwards <span>*<\/span><\/label><div class=\"fsc-input-unit\"><span class=\"wpcf7-form-control-wrap\" data-name=\"movability-rf\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" min=\"0\" max=\"100\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"movability-rf\" \/><\/span><span>%<\/span><\/div><\/div>\n        <div class=\"fsc-field\"><label>Backwards <span>*<\/span><\/label><div class=\"fsc-input-unit\"><span class=\"wpcf7-form-control-wrap\" data-name=\"movability-rb\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" min=\"0\" max=\"100\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"movability-rb\" \/><\/span><span>%<\/span><\/div><\/div>\n        <div class=\"fsc-field\"><label>Sideways <span>*<\/span><\/label><div class=\"fsc-input-unit\"><span class=\"wpcf7-form-control-wrap\" data-name=\"movability-rs\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" min=\"0\" max=\"100\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"movability-rs\" \/><\/span><span>%<\/span><\/div><\/div>\n      <\/div>\n\n      <h4>Left Side<\/h4>\n      <div class=\"fsc-grid cols-3\">\n        <div class=\"fsc-field\"><label>Forwards <span>*<\/span><\/label><div class=\"fsc-input-unit\"><span class=\"wpcf7-form-control-wrap\" data-name=\"movability-lf\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" min=\"0\" max=\"100\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"movability-lf\" \/><\/span><span>%<\/span><\/div><\/div>\n        <div class=\"fsc-field\"><label>Backwards <span>*<\/span><\/label><div class=\"fsc-input-unit\"><span class=\"wpcf7-form-control-wrap\" data-name=\"movability-lb\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" min=\"0\" max=\"100\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"movability-lb\" \/><\/span><span>%<\/span><\/div><\/div>\n        <div class=\"fsc-field\"><label>Sideways <span>*<\/span><\/label><div class=\"fsc-input-unit\"><span class=\"wpcf7-form-control-wrap\" data-name=\"movability-ls\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" min=\"0\" max=\"100\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"movability-ls\" \/><\/span><span>%<\/span><\/div><\/div>\n      <\/div>\n    <\/div>\n  <\/div>\n\n  <div class=\"fsc-step\" data-step=\"4\">\n    <div class=\"fsc-form-section\">\n      <h2>Past Diagnosis<\/h2>\n\n      <div class=\"fsc-notice\">Fields marked with * are required.<\/div>\n\n      <div class=\"fsc-field\">\n        <label>Please write a brief history of the condition<\/label>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"your-message03\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"From onset to current date, including treatments and responses\" name=\"your-message03\"><\/textarea><\/span>\n      <\/div>\n\n      <p class=\"fsc-help-text\">Have you ever been diagnosed or told you had any of the following? Please select yes or no for every question. If yes, please specify in the comment field.<\/p>\n\n      <div class=\"fsc-grid cols-2\">\n        <div class=\"fsc-field\"><label>High Blood Pressure \/ Hypertension <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pastdiag01\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"pastdiag01\"><option value=\"\">&#8212;Palun vali valik&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>Comment<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pastdiagcom01\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pastdiagcom01\" \/><\/span><\/div>\n\n        <div class=\"fsc-field\"><label>Neck pain \u2014 where? <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pastdiag02\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"pastdiag02\"><option value=\"\">&#8212;Palun vali valik&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>Comment<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pastdiagcom02\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pastdiagcom02\" \/><\/span><\/div>\n\n        <div class=\"fsc-field\"><label>Joint degeneration and\/or Arthritis <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pastdiag03\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"pastdiag03\"><option value=\"\">&#8212;Palun vali valik&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>Comment<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pastdiagcom03\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pastdiagcom03\" \/><\/span><\/div>\n\n        <div class=\"fsc-field\"><label>Haemophilia or other blood disease <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pastdiag04\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"pastdiag04\"><option value=\"\">&#8212;Palun vali valik&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>Comment<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pastdiagcom04\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pastdiagcom04\" \/><\/span><\/div>\n\n        <div class=\"fsc-field\"><label>Diabetes <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pastdiag05\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"pastdiag05\"><option value=\"\">&#8212;Palun vali valik&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>Comment<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pastdiagcom05\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pastdiagcom05\" \/><\/span><\/div>\n\n        <div class=\"fsc-field\"><label>Osteoporosis or Osteopenia <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pastdiag06\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"pastdiag06\"><option value=\"\">&#8212;Palun vali valik&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>Comment<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pastdiagcom06\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pastdiagcom06\" \/><\/span><\/div>\n\n        <div class=\"fsc-field\"><label>Whiplash injury \/ cervical sprain <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pastdiag07\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"pastdiag07\"><option value=\"\">&#8212;Palun vali valik&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>Comment<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pastdiagcom07\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pastdiagcom07\" \/><\/span><\/div>\n\n        <div class=\"fsc-field\"><label>Numbness in the hands or fingers <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pastdiag08\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"pastdiag08\"><option value=\"\">&#8212;Palun vali valik&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>Comment<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pastdiagcom08\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pastdiagcom08\" \/><\/span><\/div>\n\n        <div class=\"fsc-field\"><label>Have any relatives ever suffered a stroke? <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pastdiag09\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"pastdiag09\"><option value=\"\">&#8212;Palun vali valik&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>Comment<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pastdiagcom09\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pastdiagcom09\" \/><\/span><\/div>\n\n        <div class=\"fsc-field\"><label>Have you had cortisone shots? <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pastdiag10\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"pastdiag10\"><option value=\"\">&#8212;Palun vali valik&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>Comment<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pastdiagcom10\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pastdiagcom10\" \/><\/span><\/div>\n      <\/div>\n\n      <div class=\"fsc-field\">\n        <label>Medication \/ Allergies<\/label>\n        <span class=\"wpcf7-form-control-wrap\" data-name=\"your-message02\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Do you take medication regularly? Do you have allergies to medications?\" name=\"your-message02\"><\/textarea><\/span>\n      <\/div>\n    <\/div>\n  <\/div>\n\n  <div class=\"fsc-step\" data-step=\"5\">\n    <div class=\"fsc-form-section\">\n      <h2>Shoulder Pain and Disability Index (SPADI)<\/h2>\n\n      <p class=\"fsc-help-text\">Please rate your pain and difficulty level for each activity.<\/p>\n\n      <h3>Pain Scale \u2014 How severe is your pain?<\/h3>\n\n      <div class=\"fsc-grid cols-2\">\n        <div class=\"fsc-field\"><label>How is pain at its worst? <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pain_scale01\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"pain_scale01\"><option value=\"0 - No Pain\">0 - No Pain<\/option><option value=\"1 - Very Mild\">1 - Very Mild<\/option><option value=\"2 - Discomforting\">2 - Discomforting<\/option><option value=\"3 - Tolerable\">3 - Tolerable<\/option><option value=\"4 - Distressing\">4 - Distressing<\/option><option value=\"5 - Very Distressing\">5 - Very Distressing<\/option><option value=\"6 - Intense\">6 - Intense<\/option><option value=\"7 - Very Intense\">7 - Very Intense<\/option><option value=\"8 - Utterly Horrible\">8 - Utterly Horrible<\/option><option value=\"9 - Excruciating Unbearable\">9 - Excruciating Unbearable<\/option><option value=\"10 - Worst pain Imaginable\">10 - Worst pain Imaginable<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>When lying on involved side? <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pain_scale02\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"pain_scale02\"><option value=\"0 - No Pain\">0 - No Pain<\/option><option value=\"1 - Very Mild\">1 - Very Mild<\/option><option value=\"2 - Discomforting\">2 - Discomforting<\/option><option value=\"3 - Tolerable\">3 - Tolerable<\/option><option value=\"4 - Distressing\">4 - Distressing<\/option><option value=\"5 - Very Distressing\">5 - Very Distressing<\/option><option value=\"6 - Intense\">6 - Intense<\/option><option value=\"7 - Very Intense\">7 - Very Intense<\/option><option value=\"8 - Utterly Horrible\">8 - Utterly Horrible<\/option><option value=\"9 - Excruciating Unbearable\">9 - Excruciating Unbearable<\/option><option value=\"10 - Worst pain Imaginable\">10 - Worst pain Imaginable<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>Reaching for something on a high shelf <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pain_scale03\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"pain_scale03\"><option value=\"0 - No Pain\">0 - No Pain<\/option><option value=\"1 - Very Mild\">1 - Very Mild<\/option><option value=\"2 - Discomforting\">2 - Discomforting<\/option><option value=\"3 - Tolerable\">3 - Tolerable<\/option><option value=\"4 - Distressing\">4 - Distressing<\/option><option value=\"5 - Very Distressing\">5 - Very Distressing<\/option><option value=\"6 - Intense\">6 - Intense<\/option><option value=\"7 - Very Intense\">7 - Very Intense<\/option><option value=\"8 - Utterly Horrible\">8 - Utterly Horrible<\/option><option value=\"9 - Excruciating Unbearable\">9 - Excruciating Unbearable<\/option><option value=\"10 - Worst pain Imaginable\">10 - Worst pain Imaginable<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>Touching the back of your neck? <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pain_scale04\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"pain_scale04\"><option value=\"0 - No Pain\">0 - No Pain<\/option><option value=\"1 - Very Mild\">1 - Very Mild<\/option><option value=\"2 - Discomforting\">2 - Discomforting<\/option><option value=\"3 - Tolerable\">3 - Tolerable<\/option><option value=\"4 - Distressing\">4 - Distressing<\/option><option value=\"5 - Very Distressing\">5 - Very Distressing<\/option><option value=\"6 - Intense\">6 - Intense<\/option><option value=\"7 - Very Intense\">7 - Very Intense<\/option><option value=\"8 - Utterly Horrible\">8 - Utterly Horrible<\/option><option value=\"9 - Excruciating Unbearable\">9 - Excruciating Unbearable<\/option><option value=\"10 - Worst pain Imaginable\">10 - Worst pain Imaginable<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>Pushing with the involved arm? <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pain_scale05\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"pain_scale05\"><option value=\"0 - No Pain\">0 - No Pain<\/option><option value=\"1 - Very Mild\">1 - Very Mild<\/option><option value=\"2 - Discomforting\">2 - Discomforting<\/option><option value=\"3 - Tolerable\">3 - Tolerable<\/option><option value=\"4 - Distressing\">4 - Distressing<\/option><option value=\"5 - Very Distressing\">5 - Very Distressing<\/option><option value=\"6 - Intense\">6 - Intense<\/option><option value=\"7 - Very Intense\">7 - Very Intense<\/option><option value=\"8 - Utterly Horrible\">8 - Utterly Horrible<\/option><option value=\"9 - Excruciating Unbearable\">9 - Excruciating Unbearable<\/option><option value=\"10 - Worst pain Imaginable\">10 - Worst pain Imaginable<\/option><\/select><\/span><\/div>\n      <\/div>\n\n      <h3>Disability Scale<\/h3>\n\n      <div class=\"fsc-grid cols-2\">\n        <div class=\"fsc-field\"><label>Washing your hair? <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pain_scale06\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"pain_scale06\"><option value=\"0 - No Pain\">0 - No Pain<\/option><option value=\"1 - Very Mild\">1 - Very Mild<\/option><option value=\"2 - Discomforting\">2 - Discomforting<\/option><option value=\"3 - Tolerable\">3 - Tolerable<\/option><option value=\"4 - Distressing\">4 - Distressing<\/option><option value=\"5 - Very Distressing\">5 - Very Distressing<\/option><option value=\"6 - Intense\">6 - Intense<\/option><option value=\"7 - Very Intense\">7 - Very Intense<\/option><option value=\"8 - Utterly Horrible\">8 - Utterly Horrible<\/option><option value=\"9 - Excruciating Unbearable\">9 - Excruciating Unbearable<\/option><option value=\"10 - Worst pain Imaginable\">10 - Worst pain Imaginable<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>Washing your back? <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pain_scale07\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"pain_scale07\"><option value=\"0 - No Pain\">0 - No Pain<\/option><option value=\"1 - Very Mild\">1 - Very Mild<\/option><option value=\"2 - Discomforting\">2 - Discomforting<\/option><option value=\"3 - Tolerable\">3 - Tolerable<\/option><option value=\"4 - Distressing\">4 - Distressing<\/option><option value=\"5 - Very Distressing\">5 - Very Distressing<\/option><option value=\"6 - Intense\">6 - Intense<\/option><option value=\"7 - Very Intense\">7 - Very Intense<\/option><option value=\"8 - Utterly Horrible\">8 - Utterly Horrible<\/option><option value=\"9 - Excruciating Unbearable\">9 - Excruciating Unbearable<\/option><option value=\"10 - Worst pain Imaginable\">10 - Worst pain Imaginable<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>Putting on an undershirt or jumper? <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pain_scale08\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"pain_scale08\"><option value=\"0 - No Pain\">0 - No Pain<\/option><option value=\"1 - Very Mild\">1 - Very Mild<\/option><option value=\"2 - Discomforting\">2 - Discomforting<\/option><option value=\"3 - Tolerable\">3 - Tolerable<\/option><option value=\"4 - Distressing\">4 - Distressing<\/option><option value=\"5 - Very Distressing\">5 - Very Distressing<\/option><option value=\"6 - Intense\">6 - Intense<\/option><option value=\"7 - Very Intense\">7 - Very Intense<\/option><option value=\"8 - Utterly Horrible\">8 - Utterly Horrible<\/option><option value=\"9 - Excruciating Unbearable\">9 - Excruciating Unbearable<\/option><option value=\"10 - Worst pain Imaginable\">10 - Worst pain Imaginable<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>Putting on a shirt that buttons down the front? <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pain_scale09\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"pain_scale09\"><option value=\"0 - No Pain\">0 - No Pain<\/option><option value=\"1 - Very Mild\">1 - Very Mild<\/option><option value=\"2 - Discomforting\">2 - Discomforting<\/option><option value=\"3 - Tolerable\">3 - Tolerable<\/option><option value=\"4 - Distressing\">4 - Distressing<\/option><option value=\"5 - Very Distressing\">5 - Very Distressing<\/option><option value=\"6 - Intense\">6 - Intense<\/option><option value=\"7 - Very Intense\">7 - Very Intense<\/option><option value=\"8 - Utterly Horrible\">8 - Utterly Horrible<\/option><option value=\"9 - Excruciating Unbearable\">9 - Excruciating Unbearable<\/option><option value=\"10 - Worst pain Imaginable\">10 - Worst pain Imaginable<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>Putting on your pants? <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pain_scale10\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"pain_scale10\"><option value=\"0 - No Pain\">0 - No Pain<\/option><option value=\"1 - Very Mild\">1 - Very Mild<\/option><option value=\"2 - Discomforting\">2 - Discomforting<\/option><option value=\"3 - Tolerable\">3 - Tolerable<\/option><option value=\"4 - Distressing\">4 - Distressing<\/option><option value=\"5 - Very Distressing\">5 - Very Distressing<\/option><option value=\"6 - Intense\">6 - Intense<\/option><option value=\"7 - Very Intense\">7 - Very Intense<\/option><option value=\"8 - Utterly Horrible\">8 - Utterly Horrible<\/option><option value=\"9 - Excruciating Unbearable\">9 - Excruciating Unbearable<\/option><option value=\"10 - Worst pain Imaginable\">10 - Worst pain Imaginable<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>Placing an object on a high shelf? <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pain_scale11\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"pain_scale11\"><option value=\"0 - No Pain\">0 - No Pain<\/option><option value=\"1 - Very Mild\">1 - Very Mild<\/option><option value=\"2 - Discomforting\">2 - Discomforting<\/option><option value=\"3 - Tolerable\">3 - Tolerable<\/option><option value=\"4 - Distressing\">4 - Distressing<\/option><option value=\"5 - Very Distressing\">5 - Very Distressing<\/option><option value=\"6 - Intense\">6 - Intense<\/option><option value=\"7 - Very Intense\">7 - Very Intense<\/option><option value=\"8 - Utterly Horrible\">8 - Utterly Horrible<\/option><option value=\"9 - Excruciating Unbearable\">9 - Excruciating Unbearable<\/option><option value=\"10 - Worst pain Imaginable\">10 - Worst pain Imaginable<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>Carrying a heavy object of 10 pounds \/ 4.5kg? <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pain_scale12\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"pain_scale12\"><option value=\"0 - No Pain\">0 - No Pain<\/option><option value=\"1 - Very Mild\">1 - Very Mild<\/option><option value=\"2 - Discomforting\">2 - Discomforting<\/option><option value=\"3 - Tolerable\">3 - Tolerable<\/option><option value=\"4 - Distressing\">4 - Distressing<\/option><option value=\"5 - Very Distressing\">5 - Very Distressing<\/option><option value=\"6 - Intense\">6 - Intense<\/option><option value=\"7 - Very Intense\">7 - Very Intense<\/option><option value=\"8 - Utterly Horrible\">8 - Utterly Horrible<\/option><option value=\"9 - Excruciating Unbearable\">9 - Excruciating Unbearable<\/option><option value=\"10 - Worst pain Imaginable\">10 - Worst pain Imaginable<\/option><\/select><\/span><\/div>\n        <div class=\"fsc-field\"><label>Removing something from your back pocket? <span>*<\/span><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pain_scale13\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"pain_scale13\"><option value=\"0 - No Pain\">0 - No Pain<\/option><option value=\"1 - Very Mild\">1 - Very Mild<\/option><option value=\"2 - Discomforting\">2 - Discomforting<\/option><option value=\"3 - Tolerable\">3 - Tolerable<\/option><option value=\"4 - Distressing\">4 - Distressing<\/option><option value=\"5 - Very Distressing\">5 - Very Distressing<\/option><option value=\"6 - Intense\">6 - Intense<\/option><option value=\"7 - Very Intense\">7 - Very Intense<\/option><option value=\"8 - Utterly Horrible\">8 - Utterly Horrible<\/option><option value=\"9 - Excruciating Unbearable\">9 - Excruciating Unbearable<\/option><option value=\"10 - Worst pain Imaginable\">10 - Worst pain Imaginable<\/option><\/select><\/span><\/div>\n      <\/div>\n    <\/div>\n  <\/div>\n\n  <div class=\"fsc-step\" data-step=\"6\">\n    <div class=\"fsc-form-section\">\n      <h2>Documents<\/h2>\n\n      <p class=\"fsc-help-text\">You can upload X-rays, MRI files, pictures, videos, or medical reports.<\/p>\n\n      <div class=\"fsc-notice\">\n        Make sure files have different names. Use low resolution\/quality settings for videos and photos.\n      <\/div>\n\n      <h3>1) X-Rays<\/h3>\n      <p class=\"fsc-help-text\">Accepted file formats: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mpg, jpg, jpeg, png. Size limit per file is 4MB.<\/p>\n\n      <div class=\"fsc-grid cols-2\">\n        <div class=\"fsc-field\"><label>Right Shoulder \u2014 File 1<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"file-xray01\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".pdf,.doc,.docx,.xls,.xlsx,.csv,.txt,.rtf,.html,.zip,.mpg,.jpg,.jpeg,.png\" aria-invalid=\"false\" type=\"file\" name=\"file-xray01\" \/><\/span><\/div>\n        <div class=\"fsc-field\"><label>Right Shoulder \u2014 File 2<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"file-xray04\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".pdf,.doc,.docx,.xls,.xlsx,.csv,.txt,.rtf,.html,.zip,.mpg,.jpg,.jpeg,.png\" aria-invalid=\"false\" type=\"file\" name=\"file-xray04\" \/><\/span><\/div>\n        <div class=\"fsc-field\"><label>Left Shoulder \u2014 File 1<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"file-xray02\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".pdf,.doc,.docx,.xls,.xlsx,.csv,.txt,.rtf,.html,.zip,.mpg,.jpg,.jpeg,.png\" aria-invalid=\"false\" type=\"file\" name=\"file-xray02\" \/><\/span><\/div>\n        <div class=\"fsc-field\"><label>Left Shoulder \u2014 File 2<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"file-xray05\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".pdf,.doc,.docx,.xls,.xlsx,.csv,.txt,.rtf,.html,.zip,.mpg,.jpg,.jpeg,.png\" aria-invalid=\"false\" type=\"file\" name=\"file-xray05\" \/><\/span><\/div>\n        <div class=\"fsc-field\"><label>Neck \u2014 File 1<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"file-xray03\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".pdf,.doc,.docx,.xls,.xlsx,.csv,.txt,.rtf,.html,.zip,.mpg,.jpg,.jpeg,.png\" aria-invalid=\"false\" type=\"file\" name=\"file-xray03\" \/><\/span><\/div>\n        <div class=\"fsc-field\"><label>Neck \u2014 File 2<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"file-xray06\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".pdf,.doc,.docx,.xls,.xlsx,.csv,.txt,.rtf,.html,.zip,.mpg,.jpg,.jpeg,.png\" aria-invalid=\"false\" type=\"file\" name=\"file-xray06\" \/><\/span><\/div>\n      <\/div>\n\n      <h3>2) Medical Reports & MRI<\/h3>\n      <div class=\"fsc-grid cols-2\">\n        <div class=\"fsc-field\"><label>Medical Report \u2014 File 1<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"file-med_report01\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".pdf,.doc,.docx,.xls,.xlsx,.csv,.txt,.rtf,.html,.zip,.mpg,.jpg,.jpeg,.png\" aria-invalid=\"false\" type=\"file\" name=\"file-med_report01\" \/><\/span><\/div>\n        <div class=\"fsc-field\"><label>Medical Report \u2014 File 2<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"file-med_report02\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".pdf,.doc,.docx,.xls,.xlsx,.csv,.txt,.rtf,.html,.zip,.mpg,.jpg,.jpeg,.png\" aria-invalid=\"false\" type=\"file\" name=\"file-med_report02\" \/><\/span><\/div>\n        <div class=\"fsc-field\"><label>MRI<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"file-mri\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".pdf,.doc,.docx,.xls,.xlsx,.csv,.txt,.rtf,.html,.zip,.mpg,.jpg,.jpeg,.png\" aria-invalid=\"false\" type=\"file\" name=\"file-mri\" \/><\/span><\/div>\n      <\/div>\n\n      <h3>3) Movement videos & photos<\/h3>\n      <p class=\"fsc-help-text\">Accepted formats: pdf, rtf, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif, mov, wmv, rm. One file up to 10MB per field.<\/p>\n\n      <div class=\"fsc-grid cols-3\">\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mfile-movement\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-drag-n-drop-file d-none\" aria-invalid=\"false\" type=\"file\" multiple=\"multiple\" data-name=\"mfile-movement\" data-id=\"32845\" data-version=\"free version 1.4.0\" accept=\".\" \/><\/span>\n        \n      <\/div>\n\n      <div class=\"fsc-notice\">\n        Please check your information before submitting. 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