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    {"id":481,"date":"2026-01-13T16:24:26","date_gmt":"2026-01-13T16:24:26","guid":{"rendered":"https:\/\/surgerywebtemp.org.uk\/c82009\/?page_id=481"},"modified":"2026-01-13T16:24:26","modified_gmt":"2026-01-13T16:24:26","slug":"nhs-health-check","status":"publish","type":"page","link":"https:\/\/surgerywebtemp.org.uk\/c82009\/nhs-health-check\/","title":{"rendered":"NHS Health Check"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_15' style='display:none'><div id='gf_15' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_15' id='gform_15'  action='\/c82009\/wp-json\/wp\/v2\/pages\/481#gf_15' data-formid='15' novalidate>\n        <div id='gf_progressbar_wrapper_15' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>3<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_33' style='width:33%;'><span>33%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_15_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_15' class='c-form-list gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_15_1\" class=\"gfield nhsuk-form-group gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_15_1'>Please select your practice:&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_1' id='input_15_1' class='large gfield_select nhsuk-select '    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select...<\/option><option value='Market Harborough Medical Centre &amp; St Lukes Branch Surgery' >Market Harborough Medical Centre &amp; St Lukes Branch Surgery<\/option><option value='Husbands Bosworth Medical Centre' >Husbands Bosworth Medical Centre<\/option><\/select><\/div><\/div><fieldset id=\"field_15_3\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Who are you completing this form for?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_3_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_3' type='radio' value='Yourself'  id='choice_15_3_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_3_0' id='label_15_3_0' class='gform-field-label gform-field-label--type-inline'>Yourself<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_3_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_3' type='radio' value='Someone else'  id='choice_15_3_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_3_1' id='label_15_3_1' class='gform-field-label gform-field-label--type-inline'>Someone else<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_15_4\" class=\"gfield nhsuk-form-group gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label nhsuk-label_before_complex' >What is the patient\u2019s name?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/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_15_4'>\n                            \n                            <span id='input_15_4_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' class='nhsuk-input '  name='input_4.3' id='input_15_4_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_15_4_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_15_4_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' class='nhsuk-input '  name='input_4.6' id='input_15_4_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_15_4_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_15_5\" class=\"gfield nhsuk-form-group gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >What is the patient&#039;s date of birth?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div id='input_15_5' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_15_5_2_container'><label for='input_15_5_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select class=\"nhsuk-select\" name='input_5[]' id='input_15_5_2'   aria-required='true'  ><option value=''>Day<\/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><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_15_5_1_container'><label for='input_15_5_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select class=\"nhsuk-select\" name='input_5[]' id='input_15_5_1'   aria-required='true'  ><option value=''>Month<\/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><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_15_5_3_container'><label for='input_15_5_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select class=\"nhsuk-select\" name='input_5[]' id='input_15_5_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><fieldset id=\"field_15_6\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >What is the patient&#039;s sex?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_6_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_6' type='radio' value='Male'  id='choice_15_6_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_6_0' id='label_15_6_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_6_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_6' type='radio' value='Female'  id='choice_15_6_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_6_1' id='label_15_6_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_6_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_6' type='radio' value='gf_other_choice'  id='choice_15_6_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_6_2' id='label_15_6_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_15_6_other' class='gchoice_other_control' name='input_6_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/fieldset><div id=\"field_15_7\" class=\"gfield nhsuk-form-group gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_15_7'>What is the patient&#039;s postcode?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_15_7' type='text' value='' class='large nhsuk-input '     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_15_8\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >What is your relationship to the patient?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_8' type='radio' value='Parent'  id='choice_15_8_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_8_0' id='label_15_8_0' class='gform-field-label gform-field-label--type-inline'>Parent<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_8' type='radio' value='Guardian'  id='choice_15_8_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_8_1' id='label_15_8_1' class='gform-field-label gform-field-label--type-inline'>Guardian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_8_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_8' type='radio' value='Spouse'  id='choice_15_8_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_8_2' id='label_15_8_2' class='gform-field-label gform-field-label--type-inline'>Spouse<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_8_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_8' type='radio' value='Carer'  id='choice_15_8_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_8_3' id='label_15_8_3' class='gform-field-label gform-field-label--type-inline'>Carer<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_8_4'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_8' type='radio' value='Son'  id='choice_15_8_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_8_4' id='label_15_8_4' class='gform-field-label gform-field-label--type-inline'>Son<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_8_5'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_8' type='radio' value='Daughter'  id='choice_15_8_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_8_5' id='label_15_8_5' class='gform-field-label gform-field-label--type-inline'>Daughter<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_8_6'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_8' type='radio' value='Sibling'  id='choice_15_8_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_8_6' id='label_15_8_6' class='gform-field-label gform-field-label--type-inline'>Sibling<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_8_7'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_8' type='radio' value='gf_other_choice'  id='choice_15_8_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_8_7' id='label_15_8_7' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_15_8_other' class='gchoice_other_control' name='input_8_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_15_9\" class=\"gfield nhsuk-form-group gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label nhsuk-label_before_complex' >What is your name?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/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_15_9'>\n                            \n                            <span id='input_15_9_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' class='nhsuk-input '  name='input_9.3' id='input_15_9_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_15_9_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_15_9_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' class='nhsuk-input '  name='input_9.6' id='input_15_9_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_15_9_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_15_10\" class=\"gfield nhsuk-form-group gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >What is your date of birth?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div id='input_15_10' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_15_10_2_container'><label for='input_15_10_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select class=\"nhsuk-select\" name='input_10[]' id='input_15_10_2'   aria-required='true'  ><option value=''>Day<\/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><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_15_10_1_container'><label for='input_15_10_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select class=\"nhsuk-select\" name='input_10[]' id='input_15_10_1'   aria-required='true'  ><option value=''>Month<\/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><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_15_10_3_container'><label for='input_15_10_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select class=\"nhsuk-select\" name='input_10[]' id='input_15_10_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><fieldset id=\"field_15_11\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >What is your sex?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_11' type='radio' value='Male'  id='choice_15_11_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_11_0' id='label_15_11_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_11' type='radio' value='Female'  id='choice_15_11_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_11_1' id='label_15_11_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_11_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_11' type='radio' value='gf_other_choice'  id='choice_15_11_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_11_2' id='label_15_11_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_15_11_other' class='gchoice_other_control' name='input_11_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/fieldset><div id=\"field_15_12\" class=\"gfield nhsuk-form-group gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_15_12'>What is your postcode?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_15_12' type='text' value='' class='large nhsuk-input '     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_14\" class=\"gfield nhsuk-form-group gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_15_14'>What is your phone number?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_14' id='input_15_14' type='tel' value='' class='large nhsuk-input '   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_15\" class=\"gfield nhsuk-form-group gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_15_15'>What is your email address?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_15' id='input_15_15' type='email' value='' class='large nhsuk-input '    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_15_16\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Please specify the ethnic group you consider you belong to:&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='White \u2013 English or Welsh or Scottish or Northern Irish or British'  id='choice_15_16_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_16_0' id='label_15_16_0' class='gform-field-label gform-field-label--type-inline'>White \u2013 English or Welsh or Scottish or Northern Irish or British<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='White \u2013 Irish'  id='choice_15_16_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_16_1' id='label_15_16_1' class='gform-field-label gform-field-label--type-inline'>White \u2013 Irish<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_16_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Gypsy or Irish Traveller'  id='choice_15_16_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_16_2' id='label_15_16_2' class='gform-field-label gform-field-label--type-inline'>Gypsy or Irish Traveller<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_16_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Any other White background'  id='choice_15_16_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_16_3' id='label_15_16_3' class='gform-field-label gform-field-label--type-inline'>Any other White background<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_16_4'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Mixed White and Black Caribbean'  id='choice_15_16_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_16_4' id='label_15_16_4' class='gform-field-label gform-field-label--type-inline'>Mixed White and Black Caribbean<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_16_5'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Mixed White and Black African'  id='choice_15_16_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_16_5' id='label_15_16_5' class='gform-field-label gform-field-label--type-inline'>Mixed White and Black African<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_16_6'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Mixed White and Asian'  id='choice_15_16_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_16_6' id='label_15_16_6' class='gform-field-label gform-field-label--type-inline'>Mixed White and Asian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_16_7'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Any other Mixed \/ Multiple ethnic background'  id='choice_15_16_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_16_7' id='label_15_16_7' class='gform-field-label gform-field-label--type-inline'>Any other Mixed \/ Multiple ethnic background<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_16_8'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Asian or Asian British \u2013 Indian'  id='choice_15_16_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_16_8' id='label_15_16_8' class='gform-field-label gform-field-label--type-inline'>Asian or Asian British \u2013 Indian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_16_9'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Asian or Asian British \u2013 Pakistani'  id='choice_15_16_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_16_9' id='label_15_16_9' class='gform-field-label gform-field-label--type-inline'>Asian or Asian British \u2013 Pakistani<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_16_10'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Asian or Asian British \u2013 Bangladeshi'  id='choice_15_16_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_16_10' id='label_15_16_10' class='gform-field-label gform-field-label--type-inline'>Asian or Asian British \u2013 Bangladeshi<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_16_11'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Any other Asian background'  id='choice_15_16_11' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_16_11' id='label_15_16_11' class='gform-field-label gform-field-label--type-inline'>Any other Asian background<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_16_12'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Black or Black British \u2013 African'  id='choice_15_16_12' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_16_12' id='label_15_16_12' class='gform-field-label gform-field-label--type-inline'>Black or Black British \u2013 African<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_16_13'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Black or Black British \u2013 Caribbean'  id='choice_15_16_13' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_16_13' id='label_15_16_13' class='gform-field-label gform-field-label--type-inline'>Black or Black British \u2013 Caribbean<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_16_14'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Any other Black \/ African \/ Caribbean background'  id='choice_15_16_14' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_16_14' id='label_15_16_14' class='gform-field-label gform-field-label--type-inline'>Any other Black \/ African \/ Caribbean background<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_16_15'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Chinese'  id='choice_15_16_15' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_16_15' id='label_15_16_15' class='gform-field-label gform-field-label--type-inline'>Chinese<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_16_16'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Arab'  id='choice_15_16_16' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_16_16' id='label_15_16_16' class='gform-field-label gform-field-label--type-inline'>Arab<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_16_17'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='I do not wish to state'  id='choice_15_16_17' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_16_17' id='label_15_16_17' class='gform-field-label gform-field-label--type-inline'>I do not wish to state<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_16_18'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='gf_other_choice'  id='choice_15_16_18' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_16_18' id='label_15_16_18' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_15_16_other' class='gchoice_other_control' name='input_16_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_15_17' class='nhsuk-button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_15_2' class='gform_page' data-js='page-field-id-17' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_15_2' class='c-form-list gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_15_18\" class=\"gfield nhsuk-form-group gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Blood Pressure<\/h2><\/div><div id=\"field_15_19\" class=\"gfield nhsuk-form-group gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>To find a local pharmacy that does blood pressure readings, please visit the following websites:<\/p>\n<ul>\n<li><a href=\"https:\/\/lloydspharmacy.com\/pages\/blood-pressure-testing\" target=\"_blank\">www.lloydspharmacy.com\/pages\/blood-pressure-testing<\/a><\/li>\n<li><a href=\"https:\/\/www.boots.com\/blood-pressure-service\" target=\"_blank\">www.boots.com\/blood-pressure-service<\/a><\/li>\n<\/ul>\n<p>For a list of validated home blood pressure monitors, visit <a href=\"https:\/\/bihsoc.org\/bp-monitors\/\" target=\"_blank\">www.bihsoc.org\/bp-monitors<\/a> or discuss with your pharmacy.<\/p><\/div><div id=\"field_15_20\" class=\"gfield nhsuk-form-group gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_15_20'>Systolic (Higher)&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_15_20' type='text' value='' class='large nhsuk-input '     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_21\" class=\"gfield nhsuk-form-group gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_15_21'>Diastolic (Lower)&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_15_21' type='text' value='' class='large nhsuk-input '     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_22\" class=\"gfield nhsuk-form-group gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_15_22'>Heart Rate&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_15_22' type='text' value='' class='large nhsuk-input '     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_23\" class=\"gfield nhsuk-form-group gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">About You<\/h2><\/div><div id=\"field_15_24\" class=\"gfield nhsuk-form-group gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_15_24'>Height (in cm)&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_15_24' type='text' value='' class='large nhsuk-input '     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_25\" class=\"gfield nhsuk-form-group gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_15_25'>Weight (in kg)&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_15_25' type='text' value='' class='large nhsuk-input '     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_15_26\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Smoking Status&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_26' type='radio' value='Current smoker'  id='choice_15_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_26_0' id='label_15_26_0' class='gform-field-label gform-field-label--type-inline'>Current smoker<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_26' type='radio' value='Ex smoker'  id='choice_15_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_26_1' id='label_15_26_1' class='gform-field-label gform-field-label--type-inline'>Ex smoker<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_26_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_26' type='radio' value='Quit smoking over 3 years ago'  id='choice_15_26_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_26_2' id='label_15_26_2' class='gform-field-label gform-field-label--type-inline'>Quit smoking over 3 years ago<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_26_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_26' type='radio' value='Never smoked tobacco'  id='choice_15_26_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_26_3' id='label_15_26_3' class='gform-field-label gform-field-label--type-inline'>Never smoked tobacco<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_15_27\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >How much do you smoke?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_27' type='radio' value='Less than 1 cigarette or equivalent per day'  id='choice_15_27_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_27_0' id='label_15_27_0' class='gform-field-label gform-field-label--type-inline'>Less than 1 cigarette or equivalent per day<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_27' type='radio' value='1 \u2013 9 cigarettes or equivalent per day'  id='choice_15_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_27_1' id='label_15_27_1' class='gform-field-label gform-field-label--type-inline'>1 \u2013 9 cigarettes or equivalent per day<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_27_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_27' type='radio' value='10 \u2013 19 cigarettes or equivalent per day'  id='choice_15_27_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_27_2' id='label_15_27_2' class='gform-field-label gform-field-label--type-inline'>10 \u2013 19 cigarettes or equivalent per day<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_27_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_27' type='radio' value='20 \u2013 39 cigarettes or equivalent per day'  id='choice_15_27_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_27_3' id='label_15_27_3' class='gform-field-label gform-field-label--type-inline'>20 \u2013 39 cigarettes or equivalent per day<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_27_4'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_27' type='radio' value='40+ cigarettes or equivalent per day'  id='choice_15_27_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_27_4' id='label_15_27_4' class='gform-field-label gform-field-label--type-inline'>40+ cigarettes or equivalent per day<\/label>\n\t\t\t<\/div><\/div><\/fieldset><div id=\"field_15_28\" class=\"gfield nhsuk-form-group gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Alcohol<\/h2><\/div><div id=\"field_15_29\" class=\"gfield nhsuk-form-group gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>This is one unit of alcohol<\/strong><\/p>\n<img decoding=\"async\" src=\"https:\/\/surgerywebtemp.org.uk\/c82009\/wp-content\/uploads\/2026\/01\/alcohol-form-1-unit.jpg\" alt=\"\"\/>\n<p><strong>And each one of these, is more than one unit:<\/strong><\/p>\n<img decoding=\"async\" src=\"https:\/\/surgerywebtemp.org.uk\/c82009\/wp-content\/uploads\/2026\/01\/alcohol-form-more-unit.jpg\" alt=\"\"\/><\/div><div id=\"field_15_30\" class=\"gfield nhsuk-form-group gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_15_30'>How many units a week do you consume?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_15_30' type='text' value='' class='large nhsuk-input '     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_15_31\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >How often do you have a drink containing alcohol?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_31' type='radio' value='Never'  id='choice_15_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_31_0' id='label_15_31_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_31' type='radio' value='Monthly or less'  id='choice_15_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_31_1' id='label_15_31_1' class='gform-field-label gform-field-label--type-inline'>Monthly or less<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_31_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_31' type='radio' value='2-4 times per month'  id='choice_15_31_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_31_2' id='label_15_31_2' class='gform-field-label gform-field-label--type-inline'>2-4 times per month<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_31_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_31' type='radio' value='2-3 times per week'  id='choice_15_31_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_31_3' id='label_15_31_3' class='gform-field-label gform-field-label--type-inline'>2-3 times per week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_31_4'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_31' type='radio' value='4+ times per week'  id='choice_15_31_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_31_4' id='label_15_31_4' class='gform-field-label gform-field-label--type-inline'>4+ times per week<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_15_32\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >How many units of alcohol do you drink on a typical day when you are drinking?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_32_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_32' type='radio' value='1-2'  id='choice_15_32_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_32_0' id='label_15_32_0' class='gform-field-label gform-field-label--type-inline'>1-2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_32_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_32' type='radio' value='3-4'  id='choice_15_32_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_32_1' id='label_15_32_1' class='gform-field-label gform-field-label--type-inline'>3-4<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_32_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_32' type='radio' value='5-6'  id='choice_15_32_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_32_2' id='label_15_32_2' class='gform-field-label gform-field-label--type-inline'>5-6<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_32_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_32' type='radio' value='7-9'  id='choice_15_32_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_32_3' id='label_15_32_3' class='gform-field-label gform-field-label--type-inline'>7-9<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_32_4'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_32' type='radio' value='10+'  id='choice_15_32_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_32_4' id='label_15_32_4' class='gform-field-label gform-field-label--type-inline'>10+<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_15_33\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_33' type='radio' value='Never'  id='choice_15_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_33_0' id='label_15_33_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_33' type='radio' value='Less than monthly'  id='choice_15_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_33_1' id='label_15_33_1' class='gform-field-label gform-field-label--type-inline'>Less than monthly<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_33_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_33' type='radio' value='Monthly'  id='choice_15_33_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_33_2' id='label_15_33_2' class='gform-field-label gform-field-label--type-inline'>Monthly<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_33_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_33' type='radio' value='Weekly'  id='choice_15_33_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_33_3' id='label_15_33_3' class='gform-field-label gform-field-label--type-inline'>Weekly<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_33_4'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_33' type='radio' value='Daily or almost daily'  id='choice_15_33_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_33_4' id='label_15_33_4' class='gform-field-label gform-field-label--type-inline'>Daily or almost daily<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_15_34\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >How often during the last year have you found that you were not able to stop drinking once you had started?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_34' type='radio' value='Never'  id='choice_15_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_34_0' id='label_15_34_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_34' type='radio' value='Less than monthly'  id='choice_15_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_34_1' id='label_15_34_1' class='gform-field-label gform-field-label--type-inline'>Less than monthly<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_34_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_34' type='radio' value='Monthly'  id='choice_15_34_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_34_2' id='label_15_34_2' class='gform-field-label gform-field-label--type-inline'>Monthly<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_34_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_34' type='radio' value='Weekly'  id='choice_15_34_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_34_3' id='label_15_34_3' class='gform-field-label gform-field-label--type-inline'>Weekly<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_34_4'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_34' type='radio' value='Daily or almost daily'  id='choice_15_34_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_34_4' id='label_15_34_4' class='gform-field-label gform-field-label--type-inline'>Daily or almost daily<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_15_35\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >How often during the last year have you failed to do what was normally expected from you because of your drinking?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_35' type='radio' value='Never'  id='choice_15_35_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_35_0' id='label_15_35_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_35' type='radio' value='Less than monthly'  id='choice_15_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_35_1' id='label_15_35_1' class='gform-field-label gform-field-label--type-inline'>Less than monthly<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_35_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_35' type='radio' value='Monthly'  id='choice_15_35_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_35_2' id='label_15_35_2' class='gform-field-label gform-field-label--type-inline'>Monthly<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_35_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_35' type='radio' value='Weekly'  id='choice_15_35_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_35_3' id='label_15_35_3' class='gform-field-label gform-field-label--type-inline'>Weekly<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_35_4'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_35' type='radio' value='Daily or almost daily'  id='choice_15_35_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_35_4' id='label_15_35_4' class='gform-field-label gform-field-label--type-inline'>Daily or almost daily<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_15_36\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_36' type='radio' value='Never'  id='choice_15_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_36_0' id='label_15_36_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_36' type='radio' value='Less than monthly'  id='choice_15_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_36_1' id='label_15_36_1' class='gform-field-label gform-field-label--type-inline'>Less than monthly<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_36_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_36' type='radio' value='Monthly'  id='choice_15_36_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_36_2' id='label_15_36_2' class='gform-field-label gform-field-label--type-inline'>Monthly<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_36_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_36' type='radio' value='Weekly'  id='choice_15_36_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_36_3' id='label_15_36_3' class='gform-field-label gform-field-label--type-inline'>Weekly<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_36_4'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_36' type='radio' value='Daily or almost daily'  id='choice_15_36_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_36_4' id='label_15_36_4' class='gform-field-label gform-field-label--type-inline'>Daily or almost daily<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_15_37\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >How often during the last year have you had a feeling of guilt or remorse after drinking?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_37_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_37' type='radio' value='Never'  id='choice_15_37_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_37_0' id='label_15_37_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_37_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_37' type='radio' value='Less than monthly'  id='choice_15_37_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_37_1' id='label_15_37_1' class='gform-field-label gform-field-label--type-inline'>Less than monthly<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_37_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_37' type='radio' value='Monthly'  id='choice_15_37_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_37_2' id='label_15_37_2' class='gform-field-label gform-field-label--type-inline'>Monthly<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_37_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_37' type='radio' value='Weekly'  id='choice_15_37_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_37_3' id='label_15_37_3' class='gform-field-label gform-field-label--type-inline'>Weekly<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_37_4'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_37' type='radio' value='Daily or almost daily'  id='choice_15_37_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_37_4' id='label_15_37_4' class='gform-field-label gform-field-label--type-inline'>Daily or almost daily<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_15_38\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >How often during the last year have you been unable to remember what happened the night before because you had been drinking?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_38' type='radio' value='Never'  id='choice_15_38_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_38_0' id='label_15_38_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_38' type='radio' value='Less than monthly'  id='choice_15_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_38_1' id='label_15_38_1' class='gform-field-label gform-field-label--type-inline'>Less than monthly<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_38_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_38' type='radio' value='Monthly'  id='choice_15_38_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_38_2' id='label_15_38_2' class='gform-field-label gform-field-label--type-inline'>Monthly<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_38_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_38' type='radio' value='Weekly'  id='choice_15_38_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_38_3' id='label_15_38_3' class='gform-field-label gform-field-label--type-inline'>Weekly<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_38_4'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_38' type='radio' value='Daily or almost daily'  id='choice_15_38_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_38_4' id='label_15_38_4' class='gform-field-label gform-field-label--type-inline'>Daily or almost daily<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_15_39\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Have you or somebody else been injured as a result of your drinking?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_39_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_39' type='radio' value='No'  id='choice_15_39_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_39_0' id='label_15_39_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_39_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_39' type='radio' value='Yes, but not in the last year'  id='choice_15_39_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_39_1' id='label_15_39_1' class='gform-field-label gform-field-label--type-inline'>Yes, but not in the last year<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_39_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_39' type='radio' value='Yes, in the last year'  id='choice_15_39_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_39_2' id='label_15_39_2' class='gform-field-label gform-field-label--type-inline'>Yes, in the last year<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_15_40\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_40_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_40' type='radio' value='No'  id='choice_15_40_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_40_0' id='label_15_40_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_40_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_40' type='radio' value='Yes, but not in the last year'  id='choice_15_40_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_40_1' id='label_15_40_1' class='gform-field-label gform-field-label--type-inline'>Yes, but not in the last year<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_40_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_40' type='radio' value='Yes, in the last year'  id='choice_15_40_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_40_2' id='label_15_40_2' class='gform-field-label gform-field-label--type-inline'>Yes, in the last year<\/label>\n\t\t\t<\/div><\/div><\/fieldset><div id=\"field_15_41\" class=\"gfield nhsuk-form-group gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Physical Activity<\/h2><\/div><fieldset id=\"field_15_42\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Please tell us the type and amount of physical activity involved in your work:&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_42_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_42' type='radio' value='I am not in employment (e.g. retired, retired for health reasons, unemployed, full-time carer etc.)'  id='choice_15_42_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_42_0' id='label_15_42_0' class='gform-field-label gform-field-label--type-inline'>I am not in employment (e.g. retired, retired for health reasons, unemployed, full-time carer etc.)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_42_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_42' type='radio' value='I spend most of my time at work sitting (such as in an office)'  id='choice_15_42_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_42_1' id='label_15_42_1' class='gform-field-label gform-field-label--type-inline'>I spend most of my time at work sitting (such as in an office)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_42_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_42' type='radio' value='I spend most of my time at work standing or walking. However, my work does not require much intense physical effort (e.g. shop assistant, hairdresser, security guard, childminder, etc.)'  id='choice_15_42_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_42_2' id='label_15_42_2' class='gform-field-label gform-field-label--type-inline'>I spend most of my time at work standing or walking. However, my work does not require much intense physical effort (e.g. shop assistant, hairdresser, security guard, childminder, etc.)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_42_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_42' type='radio' value='My work involves definite physical effort including handling of heavy objects and use of tools (e.g. plumber, electrician, carpenter, cleaner, hospital nurse, gardener, postal delivery workers etc.)'  id='choice_15_42_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_42_3' id='label_15_42_3' class='gform-field-label gform-field-label--type-inline'>My work involves definite physical effort including handling of heavy objects and use of tools (e.g. plumber, electrician, carpenter, cleaner, hospital nurse, gardener, postal delivery workers etc.)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_42_4'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_42' type='radio' value='My work involves vigorous physical activity including handling of very heavy objects (e.g. scaffolder, construction worker, refuse collector, etc.)'  id='choice_15_42_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_42_4' id='label_15_42_4' class='gform-field-label gform-field-label--type-inline'>My work involves vigorous physical activity including handling of very heavy objects (e.g. scaffolder, construction worker, refuse collector, etc.)<\/label>\n\t\t\t<\/div><\/div><\/fieldset><div id=\"field_15_43\" class=\"gfield nhsuk-form-group gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>During the last week, how many hours did you spend on each of the following activities?<\/strong><\/p><\/div><fieldset id=\"field_15_44\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Physical exercise such as swimming, jogging, aerobics, football, tennis, gym workout etc.?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_44' type='radio' value='None'  id='choice_15_44_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_44_0' id='label_15_44_0' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_44' type='radio' value='Some but less than 1 hour'  id='choice_15_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_44_1' id='label_15_44_1' class='gform-field-label gform-field-label--type-inline'>Some but less than 1 hour<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_44_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_44' type='radio' value='1 hour but less than 3 hours'  id='choice_15_44_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_44_2' id='label_15_44_2' class='gform-field-label gform-field-label--type-inline'>1 hour but less than 3 hours<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_44_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_44' type='radio' value='3 hours or more'  id='choice_15_44_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_44_3' id='label_15_44_3' class='gform-field-label gform-field-label--type-inline'>3 hours or more<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_15_45\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Cycling, including cycling to work and during leisure time?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_45_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_45' type='radio' value='None'  id='choice_15_45_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_45_0' id='label_15_45_0' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_45_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_45' type='radio' value='Some but less than 1 hour'  id='choice_15_45_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_45_1' id='label_15_45_1' class='gform-field-label gform-field-label--type-inline'>Some but less than 1 hour<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_45_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_45' type='radio' value='1 hour but less than 3 hours'  id='choice_15_45_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_45_2' id='label_15_45_2' class='gform-field-label gform-field-label--type-inline'>1 hour but less than 3 hours<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_45_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_45' type='radio' value='3 hours or more'  id='choice_15_45_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_45_3' id='label_15_45_3' class='gform-field-label gform-field-label--type-inline'>3 hours or more<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_15_46\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Walking, including walking to work, shopping, for pleasure etc.?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_46_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_46' type='radio' value='None'  id='choice_15_46_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_46_0' id='label_15_46_0' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_46_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_46' type='radio' value='Some but less than 1 hour'  id='choice_15_46_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_46_1' id='label_15_46_1' class='gform-field-label gform-field-label--type-inline'>Some but less than 1 hour<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_46_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_46' type='radio' value='1 hour but less than 3 hours'  id='choice_15_46_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_46_2' id='label_15_46_2' class='gform-field-label gform-field-label--type-inline'>1 hour but less than 3 hours<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_46_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_46' type='radio' value='3 hours or more'  id='choice_15_46_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_46_3' id='label_15_46_3' class='gform-field-label gform-field-label--type-inline'>3 hours or more<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_15_47\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Housework or childcare?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_47' type='radio' value='None'  id='choice_15_47_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_47_0' id='label_15_47_0' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_47' type='radio' value='Some but less than 1 hour'  id='choice_15_47_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_47_1' id='label_15_47_1' class='gform-field-label gform-field-label--type-inline'>Some but less than 1 hour<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_47_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_47' type='radio' value='1 hour but less than 3 hours'  id='choice_15_47_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_47_2' id='label_15_47_2' class='gform-field-label gform-field-label--type-inline'>1 hour but less than 3 hours<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_47_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_47' type='radio' value='3 hours or more'  id='choice_15_47_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_47_3' id='label_15_47_3' class='gform-field-label gform-field-label--type-inline'>3 hours or more<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_15_48\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Gardening or DIY?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_48_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_48' type='radio' value='None'  id='choice_15_48_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_48_0' id='label_15_48_0' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_48_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_48' type='radio' value='Some but less than 1 hour'  id='choice_15_48_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_48_1' id='label_15_48_1' class='gform-field-label gform-field-label--type-inline'>Some but less than 1 hour<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_48_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_48' type='radio' value='1 hour but less than 3 hours'  id='choice_15_48_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_48_2' id='label_15_48_2' class='gform-field-label gform-field-label--type-inline'>1 hour but less than 3 hours<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_48_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_48' type='radio' value='3 hours or more'  id='choice_15_48_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_48_3' id='label_15_48_3' class='gform-field-label gform-field-label--type-inline'>3 hours or more<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_15_49\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >How would you describe your usual walking pace?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_49_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_49' type='radio' value='Slow pace (ie. less than 3mph)'  id='choice_15_49_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_49_0' id='label_15_49_0' class='gform-field-label gform-field-label--type-inline'>Slow pace (ie. less than 3mph)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_49_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_49' type='radio' value='Steady average pace'  id='choice_15_49_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_49_1' id='label_15_49_1' class='gform-field-label gform-field-label--type-inline'>Steady average pace<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_49_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_49' type='radio' value='Brisk pace'  id='choice_15_49_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_49_2' id='label_15_49_2' class='gform-field-label gform-field-label--type-inline'>Brisk pace<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_49_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_49' type='radio' value='Fast pace (ie. over 4mph)'  id='choice_15_49_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_49_3' id='label_15_49_3' class='gform-field-label gform-field-label--type-inline'>Fast pace (ie. over 4mph)<\/label>\n\t\t\t<\/div><\/div><\/fieldset><div id=\"field_15_50\" class=\"gfield nhsuk-form-group gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Family History<\/h2><\/div><fieldset id=\"field_15_51\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Do you have a family history of angina in a 1st degree female relative under 65?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_51_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_51' type='radio' value='Yes'  id='choice_15_51_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_51_0' id='label_15_51_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_51_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_51' type='radio' value='No'  id='choice_15_51_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_51_1' id='label_15_51_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_15_52\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Do you have a family history of angina in a 1st degree male relative under 55?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_52_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_52' type='radio' value='Yes'  id='choice_15_52_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_52_0' id='label_15_52_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_52_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_52' type='radio' value='No'  id='choice_15_52_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_52_1' id='label_15_52_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_15_53\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Do you have a family history of myocardial infarction in a 1st degree female relative under 65?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_53_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_53' type='radio' value='Yes'  id='choice_15_53_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_53_0' id='label_15_53_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_53_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_53' type='radio' value='No'  id='choice_15_53_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_53_1' id='label_15_53_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_15_54\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Do you have a family history of myocardial infarction in a 1st degree male relative under 55?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_54_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_54' type='radio' value='Yes'  id='choice_15_54_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_54_0' id='label_15_54_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_54_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_54' type='radio' value='No'  id='choice_15_54_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_54_1' id='label_15_54_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_15_55\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Do you have a family history of cardiovascular disease in a 1st degree female relative under 65?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_55' type='radio' value='Yes'  id='choice_15_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_55_0' id='label_15_55_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_55' type='radio' value='No'  id='choice_15_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_55_1' id='label_15_55_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_15_56\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Do you have a family history of cardiovascular disease in a 1st degree male relative under 55?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_56_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_56' type='radio' value='Yes'  id='choice_15_56_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_56_0' id='label_15_56_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_56_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_56' type='radio' value='No'  id='choice_15_56_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_56_1' id='label_15_56_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_15_57\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Do you have a family history of diabetes mellitus?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_57_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_57' type='radio' value='Yes'  id='choice_15_57_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_57_0' id='label_15_57_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_57_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_57' type='radio' value='No'  id='choice_15_57_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_57_1' id='label_15_57_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_15_58\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Do you have a family history of familial hypercholesterolaemia?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_58_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_58' type='radio' value='Yes'  id='choice_15_58_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_58_0' id='label_15_58_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_58_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_58' type='radio' value='No'  id='choice_15_58_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_58_1' id='label_15_58_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_15_59\" class=\"gfield nhsuk-form-group gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='nhsuk-label gform-field-label' >Do you have a family history of any other diseases or conditions?&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_radio nhsuk-radios'>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_59_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_59' type='radio' value='Yes'  id='choice_15_59_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_59_0' id='label_15_59_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_15_59_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_59' type='radio' value='No'  id='choice_15_59_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_15_59_1' id='label_15_59_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_15_60' class='nhsuk-button nhsuk-button--reverse gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_15_60' class='nhsuk-button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_15_3' class='gform_page' data-js='page-field-id-60' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_15_3' class='c-form-list gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_15_61\" class=\"gfield nhsuk-form-group gfield--type-html gfield--input-type-html summaryList gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><dl class=\"nhsuk-summary-list\">{all_fields}<\/dl><\/div><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_15' class='nhsuk-button nhsuk-button--reverse gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='submit' id='gform_submit_button_15' class='nhsuk-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> <input type='hidden' name='gform_ajax' value='form_id=15&amp;title=&amp;description=&amp;tabindex=0&amp;theme=gravity-theme&amp;styles=[]&amp;hash=3907faaa57124da55dad55c78ae18197' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_15' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_15' id='gform_theme_15' 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