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    {"id":527,"date":"2026-07-16T17:55:44","date_gmt":"2026-07-16T16:55:44","guid":{"rendered":"https:\/\/surgerywebtemp.org.uk\/g81613\/?page_id=527"},"modified":"2026-07-16T17:55:44","modified_gmt":"2026-07-16T16:55:44","slug":"asthma-review-form","status":"publish","type":"page","link":"https:\/\/surgerywebtemp.org.uk\/g81613\/asthma-review-form\/","title":{"rendered":"Asthma Review Form"},"content":{"rendered":"<p>This form is used for your annual asthma review. Please answer the questions and submit this form to us. If your symptoms are deteriorating or you have any concerns, please make an appointment to the respiratory nurse or a Doctor as well.<\/p>\n<script>\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<\/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_14' style='display:none'><div id='gf_14' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_14' id='gform_14'  action='\/g81613\/wp-json\/wp\/v2\/pages\/527#gf_14' data-formid='14' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_14' class='c-form-list gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_14_37\" class=\"gfield nhsuk-form-group gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_14_37'><span class='gform-field-label__text'>Email<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag\">Optional<\/span><\/label><div class='ginput_container'><input name='input_37' id='input_14_37' type='text' value='' autocomplete='new-password'\/><\/div><span class='nhsuk-hint' id='gfield_description_14_37'>This field is for validation purposes and should be left unchanged.<\/span><\/div><div id=\"field_14_1\" 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_14_1'><span class='gform-field-label__text'>Full Name<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_14_1' type='text' value='' class='large nhsuk-input '     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_14_3\" 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' ><span class='gform-field-label__text'>Date of Birth<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div id='input_14_3' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_14_3_2_container'><label for='input_14_3_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>DD<\/label><select class=\"nhsuk-select\" name='input_3[]' id='input_14_3_2'   aria-required='true'  ><option value=''>DD<\/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_14_3_1_container'><label for='input_14_3_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>MM<\/label><select class=\"nhsuk-select\" name='input_3[]' id='input_14_3_1'   aria-required='true'  ><option value=''>MM<\/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_14_3_3_container'><label for='input_14_3_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>YYYY<\/label><select class=\"nhsuk-select\" name='input_3[]' id='input_14_3_3'   aria-required='true'  ><option value=''>YYYY<\/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><div id=\"field_14_4\" class=\"gfield nhsuk-form-group gfield--type-email gfield--input-type-email 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_14_4'><span class='gform-field-label__text'>Email<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_4' id='input_14_4' type='email' value='' class='large nhsuk-input '    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_14_5\" 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_14_5'><span class='gform-field-label__text'>Phone Number<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_14_5' type='text' value='' class='large nhsuk-input '     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_6\" 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\">Please complete the following questions to allow your health care professional to assess your asthma.<\/h2><\/div><fieldset id=\"field_14_7\" 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 gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>How often does your asthma cause symptoms during the day?<\/span>&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_14_7_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_7' type='radio' value='Never'  id='choice_14_7_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_7_0' id='label_14_7_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_14_7_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_7' type='radio' value='1 to 2 times per month'  id='choice_14_7_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_7_1' id='label_14_7_1' class='gform-field-label gform-field-label--type-inline'>1 to 2 times per month<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_7_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_7' type='radio' value='1 to 2 times per week'  id='choice_14_7_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_7_2' id='label_14_7_2' class='gform-field-label gform-field-label--type-inline'>1 to 2 times per week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_7_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_7' type='radio' value='Most days'  id='choice_14_7_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_7_3' id='label_14_7_3' class='gform-field-label gform-field-label--type-inline'>Most days<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_14_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 gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>How often does your asthma cause symptoms at night?<\/span>&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_14_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_8' type='radio' value='Never'  id='choice_14_8_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_8_0' id='label_14_8_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_14_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_8' type='radio' value='1 to 2 times per month'  id='choice_14_8_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_8_1' id='label_14_8_1' class='gform-field-label gform-field-label--type-inline'>1 to 2 times per month<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_8_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_8' type='radio' value='1 to 2 times per week'  id='choice_14_8_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_8_2' id='label_14_8_2' class='gform-field-label gform-field-label--type-inline'>1 to 2 times per week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_8_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_8' type='radio' value='Most days'  id='choice_14_8_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_8_3' id='label_14_8_3' class='gform-field-label gform-field-label--type-inline'>Most days<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_14_9\" 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 gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>How often does your asthma limit your activities?<\/span>&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_14_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_9' type='radio' value='Never'  id='choice_14_9_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_9_0' id='label_14_9_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_14_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_9' type='radio' value='1 to 2 times per month'  id='choice_14_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_9_1' id='label_14_9_1' class='gform-field-label gform-field-label--type-inline'>1 to 2 times per month<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_9_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_9' type='radio' value='1 to 2 times per week'  id='choice_14_9_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_9_2' id='label_14_9_2' class='gform-field-label gform-field-label--type-inline'>1 to 2 times per week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_9_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_9' type='radio' value='Most days'  id='choice_14_9_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_9_3' id='label_14_9_3' class='gform-field-label gform-field-label--type-inline'>Most days<\/label>\n\t\t\t<\/div><\/div><\/fieldset><div id=\"field_14_10\" 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_14_10'><span class='gform-field-label__text'>How many asthma exacerbations (attacked) have you had in the past year?<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_14_10' type='text' value='' class='large nhsuk-input '     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_11\" 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_14_11'><span class='gform-field-label__text'>How many times have you attended Accident and Emergency Department since your last asthma review?<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_14_11' type='text' value='' class='large nhsuk-input '     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_12\" 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\">Inhaler Technique<\/h2><\/div><fieldset id=\"field_14_13\" class=\"gfield nhsuk-form-group gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label nhsuk-label_before_complex' ><span class='gform-field-label__text'>Please select the types of inhalers that you use<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox nhsuk_checkbox ' id='input_14_13'><div class='gchoice nhsuk-checkboxes__item gchoice_14_13_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input nhsuk-checkboxes__input' name='input_13.1' type='checkbox'  value='Metered Dose Inhaler'  id='choice_14_13_1'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_14_13_1' id='label_14_13_1' class='gform-field-label gform-field-label--type-inline'>Metered Dose Inhaler<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice nhsuk-checkboxes__item gchoice_14_13_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input nhsuk-checkboxes__input' name='input_13.2' type='checkbox'  value='Autohaler'  id='choice_14_13_2'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_14_13_2' id='label_14_13_2' class='gform-field-label gform-field-label--type-inline'>Autohaler<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice nhsuk-checkboxes__item gchoice_14_13_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input nhsuk-checkboxes__input' name='input_13.3' type='checkbox'  value='Accuhaler'  id='choice_14_13_3'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_14_13_3' id='label_14_13_3' class='gform-field-label gform-field-label--type-inline'>Accuhaler<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice nhsuk-checkboxes__item gchoice_14_13_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input nhsuk-checkboxes__input' name='input_13.4' type='checkbox'  value='EasiBreathe Inhaler'  id='choice_14_13_4'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_14_13_4' id='label_14_13_4' class='gform-field-label gform-field-label--type-inline'>EasiBreathe Inhaler<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice nhsuk-checkboxes__item gchoice_14_13_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input nhsuk-checkboxes__input' name='input_13.5' type='checkbox'  value='Easyhaler'  id='choice_14_13_5'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_14_13_5' id='label_14_13_5' class='gform-field-label gform-field-label--type-inline'>Easyhaler<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice nhsuk-checkboxes__item gchoice_14_13_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input nhsuk-checkboxes__input' name='input_13.6' type='checkbox'  value='Turbohaler'  id='choice_14_13_6'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_14_13_6' id='label_14_13_6' class='gform-field-label gform-field-label--type-inline'>Turbohaler<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice nhsuk-checkboxes__item gchoice_14_13_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input nhsuk-checkboxes__input' name='input_13.7' type='checkbox'  value='Small Volume Spacer'  id='choice_14_13_7'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_14_13_7' id='label_14_13_7' class='gform-field-label gform-field-label--type-inline'>Small Volume Spacer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice nhsuk-checkboxes__item gchoice_14_13_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input nhsuk-checkboxes__input' name='input_13.8' type='checkbox'  value='Large Volume Spacer'  id='choice_14_13_8'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_14_13_8' id='label_14_13_8' class='gform-field-label gform-field-label--type-inline'>Large Volume Spacer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice nhsuk-checkboxes__item gchoice_14_13_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input nhsuk-checkboxes__input' name='input_13.9' type='checkbox'  value='My inhaler is not listed here'  id='choice_14_13_9'   \/>\n\t\t\t\t\t\t\t\t<label class=\"nhsuk-label nhsuk-checkboxes__label\" for='choice_14_13_9' id='label_14_13_9' class='gform-field-label gform-field-label--type-inline'>My inhaler is not listed here<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_14_14\" 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_14_14'><span class='gform-field-label__text'>Please specify your inhaler<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_14_14' type='text' value='' class='large nhsuk-input '     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_14_15\" 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\">Lifestyle - Alcohol<\/h2><\/div><fieldset id=\"field_14_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 gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>How often do you have a drink containing alcohol?<\/span>&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_14_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Never'  id='choice_14_16_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_16_0' id='label_14_16_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_14_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='Monthly or less'  id='choice_14_16_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_16_1' id='label_14_16_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_14_16_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='2-4 times a month'  id='choice_14_16_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_16_2' id='label_14_16_2' class='gform-field-label gform-field-label--type-inline'>2-4 times a month<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_16_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='2-3 times a week'  id='choice_14_16_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_16_3' id='label_14_16_3' class='gform-field-label gform-field-label--type-inline'>2-3 times a week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_16_4'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_16' type='radio' value='4 times or more a week'  id='choice_14_16_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_16_4' id='label_14_16_4' class='gform-field-label gform-field-label--type-inline'>4 times or more a week<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_14_17\" 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 gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>How many units of alcohol do you drink on a typical day drinking?<\/span>&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_14_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_17' type='radio' value='1 - 2'  id='choice_14_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_17_0' id='label_14_17_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_14_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_17' type='radio' value='3 - 4'  id='choice_14_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_17_1' id='label_14_17_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_14_17_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_17' type='radio' value='5 - 6'  id='choice_14_17_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_17_2' id='label_14_17_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_14_17_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_17' type='radio' value='7 - 9'  id='choice_14_17_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_17_3' id='label_14_17_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_14_17_4'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_17' type='radio' value='10+'  id='choice_14_17_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_17_4' id='label_14_17_4' class='gform-field-label gform-field-label--type-inline'>10+<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_14_18\" 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 gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>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?<\/span>&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_14_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_18' type='radio' value='Never'  id='choice_14_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_18_0' id='label_14_18_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_14_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_18' type='radio' value='Less than monthly'  id='choice_14_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_18_1' id='label_14_18_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_14_18_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_18' type='radio' value='Monthly'  id='choice_14_18_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_18_2' id='label_14_18_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_14_18_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_18' type='radio' value='Weekly'  id='choice_14_18_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_18_3' id='label_14_18_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_14_18_4'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_18' type='radio' value='Daily or almost daily'  id='choice_14_18_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_18_4' id='label_14_18_4' class='gform-field-label gform-field-label--type-inline'>Daily or almost daily<\/label>\n\t\t\t<\/div><\/div><\/fieldset><div id=\"field_14_19\" 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\">Lifestyle - Smoking<\/h2><\/div><fieldset id=\"field_14_20\" 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 gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>Do you smoke?<\/span>&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_14_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_20' type='radio' value='Never smoked'  id='choice_14_20_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_20_0' id='label_14_20_0' class='gform-field-label gform-field-label--type-inline'>Never smoked<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_20' type='radio' value='Ex-smoker'  id='choice_14_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_20_1' id='label_14_20_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_14_20_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_20' type='radio' value='Trivial smoker (less than 1 cigarette per day)'  id='choice_14_20_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_20_2' id='label_14_20_2' class='gform-field-label gform-field-label--type-inline'>Trivial smoker (less than 1 cigarette per day)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_20_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_20' type='radio' value='Light Smoker (1-9 cigarettes per day)'  id='choice_14_20_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_20_3' id='label_14_20_3' class='gform-field-label gform-field-label--type-inline'>Light Smoker (1-9 cigarettes per day)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_20_4'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_20' type='radio' value='Moderate smoker (10-19 cigarettes per day)'  id='choice_14_20_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_20_4' id='label_14_20_4' class='gform-field-label gform-field-label--type-inline'>Moderate smoker (10-19 cigarettes per day)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_20_5'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_20' type='radio' value='Heavy smoker (20-39 cigarettes per day)'  id='choice_14_20_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_20_5' id='label_14_20_5' class='gform-field-label gform-field-label--type-inline'>Heavy smoker (20-39 cigarettes per day)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_20_6'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_20' type='radio' value='Very heavy smoker (40 or more cigarettes per day)'  id='choice_14_20_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_20_6' id='label_14_20_6' class='gform-field-label gform-field-label--type-inline'>Very heavy smoker (40 or more cigarettes per day)<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_14_21\" 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 gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>Do you use an e-cigarette?<\/span>&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_14_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_21' type='radio' value='No'  id='choice_14_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_21_0' id='label_14_21_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_14_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_21' type='radio' value='Ex-user'  id='choice_14_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_21_1' id='label_14_21_1' class='gform-field-label gform-field-label--type-inline'>Ex-user<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_21_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_21' type='radio' value='Yes'  id='choice_14_21_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_21_2' id='label_14_21_2' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_14_22\" 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 gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>Would you like help to quit smoking?<\/span>&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_14_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_22' type='radio' value='Yes'  id='choice_14_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_22_0' id='label_14_22_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_14_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_22' type='radio' value='No'  id='choice_14_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_22_1' id='label_14_22_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/fieldset><div id=\"field_14_23\" 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>For further information, please see: <a href=\"https:\/\/www.nhs.uk\/better-health\/quit-smoking\/\" target=\"_blank\">nhs.uk\/quit-smoking<\/a><\/p><\/div><div id=\"field_14_24\" 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\">Asthma Control Test Score<\/h2><\/div><fieldset id=\"field_14_25\" 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 gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home?<\/span>&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_14_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_25' type='radio' value='1'  id='choice_14_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_25_0' id='label_14_25_0' class='gform-field-label gform-field-label--type-inline'>All of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_25' type='radio' value='2'  id='choice_14_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_25_1' id='label_14_25_1' class='gform-field-label gform-field-label--type-inline'>Most of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_25_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_25' type='radio' value='3'  id='choice_14_25_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_25_2' id='label_14_25_2' class='gform-field-label gform-field-label--type-inline'>Some of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_25_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_25' type='radio' value='4'  id='choice_14_25_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_25_3' id='label_14_25_3' class='gform-field-label gform-field-label--type-inline'>A little of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_25_4'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_25' type='radio' value='5'  id='choice_14_25_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_25_4' id='label_14_25_4' class='gform-field-label gform-field-label--type-inline'>None of the time<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_14_28\" 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 gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>How often have you had shortness of breath?<\/span>&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_14_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_28' type='radio' value='1'  id='choice_14_28_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_28_0' id='label_14_28_0' class='gform-field-label gform-field-label--type-inline'>More than once a day<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_28' type='radio' value='2'  id='choice_14_28_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_28_1' id='label_14_28_1' class='gform-field-label gform-field-label--type-inline'>Once a day<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_28_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_28' type='radio' value='3'  id='choice_14_28_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_28_2' id='label_14_28_2' class='gform-field-label gform-field-label--type-inline'>3-6 times a week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_28_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_28' type='radio' value='4'  id='choice_14_28_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_28_3' id='label_14_28_3' class='gform-field-label gform-field-label--type-inline'>1-2 times a week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_28_4'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_28' type='radio' value='5'  id='choice_14_28_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_28_4' id='label_14_28_4' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_14_29\" 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 gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>How often did your asthma symptoms (wheezing, coughing, chest tightness, shortness of breath) wake you up at night or earlier than usual in the morning?<\/span>&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_14_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_29' type='radio' value='1'  id='choice_14_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_29_0' id='label_14_29_0' class='gform-field-label gform-field-label--type-inline'>4 or more times a week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_29' type='radio' value='2'  id='choice_14_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_29_1' id='label_14_29_1' class='gform-field-label gform-field-label--type-inline'>2-3 nights a week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_29_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_29' type='radio' value='3'  id='choice_14_29_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_29_2' id='label_14_29_2' class='gform-field-label gform-field-label--type-inline'>Once a week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_29_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_29' type='radio' value='4'  id='choice_14_29_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_29_3' id='label_14_29_3' class='gform-field-label gform-field-label--type-inline'>Once or twice<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_29_4'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_29' type='radio' value='5'  id='choice_14_29_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_29_4' id='label_14_29_4' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_14_30\" 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 gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>How often have you used your reliever inhaler (usually blue)?<\/span>&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_14_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_30' type='radio' value='1'  id='choice_14_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_30_0' id='label_14_30_0' class='gform-field-label gform-field-label--type-inline'>3 or more times a day<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_30' type='radio' value='2'  id='choice_14_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_30_1' id='label_14_30_1' class='gform-field-label gform-field-label--type-inline'>1-2 times a day<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_30_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_30' type='radio' value='3'  id='choice_14_30_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_30_2' id='label_14_30_2' class='gform-field-label gform-field-label--type-inline'>2-3 times a week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_30_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_30' type='radio' value='4'  id='choice_14_30_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_30_3' id='label_14_30_3' class='gform-field-label gform-field-label--type-inline'>Once a week or less<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_30_4'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_30' type='radio' value='5'  id='choice_14_30_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_30_4' id='label_14_30_4' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div><\/div><\/fieldset><fieldset id=\"field_14_31\" 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 gfield--choice-align-vertical\"  ><legend class='nhsuk-label gform-field-label' ><span class='gform-field-label__text'>How would you rate your asthma control?<\/span>&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_14_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_31' type='radio' value='1'  id='choice_14_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_31_0' id='label_14_31_0' class='gform-field-label gform-field-label--type-inline'>Not controlled<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_31' type='radio' value='2'  id='choice_14_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_31_1' id='label_14_31_1' class='gform-field-label gform-field-label--type-inline'>Poorly controlled<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_31_2'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_31' type='radio' value='3'  id='choice_14_31_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_31_2' id='label_14_31_2' class='gform-field-label gform-field-label--type-inline'>Somewhat controlled<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_31_3'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_31' type='radio' value='4'  id='choice_14_31_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_31_3' id='label_14_31_3' class='gform-field-label gform-field-label--type-inline'>Well controlled<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice nhsuk-radios__item gchoice_14_31_4'>\n\t\t\t\t\t<input class='gfield-choice-input nhsuk-radios__input' name='input_31' type='radio' value='5'  id='choice_14_31_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label class=\"nhsuk-label nhsuk-radios__label\" for='choice_14_31_4' id='label_14_31_4' class='gform-field-label gform-field-label--type-inline'>Completely controlled<\/label>\n\t\t\t<\/div><\/div><\/fieldset><div id=\"field_14_27\" class=\"gfield nhsuk-form-group gfield--type-number gfield--input-type-number gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_14_27'><span class='gform-field-label__text'>Your Calculated Asthma score<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag nhsuk-tag--grey\">Required<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_27' id='input_14_27' type='text' step='any'   value='' class='large nhsuk-input  gform-text-input-reset'  readonly=\"readonly\"   aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_14_32\" 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\"  ><div style=\"background: red; padding: 30px; color: #fff;\">\n<p>Your score is less than 20.<\/p>\n<p>Your asthma may not have been controlled during the past 4 weeks.<\/p>\n<p>Your doctor or nurse can recommend an asthma action plan to help improve your asthma control.<\/p>\n<\/div><\/div><div id=\"field_14_33\" 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\"  ><div style=\"background: orange; padding: 30px; color: #000;\">\n<p>Your score is between 20 and 24.<\/p>\n<p>Your asthma appears to have been reasonably well controlled during the past 4 weeks.<\/p>\n<p>However, if you are experiencing symptoms your doctor or nurse may be able to help you.<\/p>\n<\/div><\/div><div id=\"field_14_34\" 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\"  ><div style=\"background: green; padding: 30px; color: #fff;\">\n<p>Your score is 25, well done!<\/p>\n<p>Your asthma appears to have been under control over the last 4 weeks.<\/p>\n<p>However, if you are experiencing any problems with your asthma, you should see your doctor or nurse.<\/p>\n<\/div><\/div><div id=\"field_14_35\" 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\">Further Questions<\/h2><\/div><div id=\"field_14_36\" class=\"gfield nhsuk-form-group gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='nhsuk-label gform-field-label' for='input_14_36'><span class='gform-field-label__text'>I have the following information, questions or concerns that I would like to raise with my Asthma Nurse or Doctor<\/span>&nbsp;&nbsp;<span class=\"nhsuk-tag\">Optional<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_36' id='input_14_36' class='textarea nhsuk-textarea  small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <button 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