{"id":1788,"date":"2020-04-20T08:51:41","date_gmt":"2020-04-20T04:51:41","guid":{"rendered":"https:\/\/agency.securimed.ca\/questionnaire-medical-covid-19\/"},"modified":"2020-11-30T21:13:44","modified_gmt":"2020-12-01T02:13:44","slug":"covidmed","status":"publish","type":"page","link":"https:\/\/agency.securimed.ca\/en\/covidmed\/","title":{"rendered":"COVID-19 Medical Questionnaire"},"content":{"rendered":"\n\t<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 gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_3' style='display:none'><div id='gf_3' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_3' id='gform_3'  action='\/en\/wp-json\/wp\/v2\/pages\/1788#gf_3' data-formid='3' novalidate>\n        <div id='gf_progressbar_wrapper_3' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<h3 class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>21<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_red' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_red percentbar_4' style='width:4%;'><span>4%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_3_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_1\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_1'>Entreprise identification number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_3_1' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_3_2' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_2' class='gform_page' data-js='page-field-id-2' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_3\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Identification<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><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_3_3'>\n                            \n                            <span id='input_3_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_3_3_3' value=''   aria-required='true'   placeholder='First name'  \/>\n                                                    <label for='input_3_3_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.6' id='input_3_3_6' value=''   aria-required='true'   placeholder='Last name'  \/>\n                                                    <label for='input_3_3_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_3_7\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Adresse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_city has_state ginput_container_address gform-grid-row' id='input_3_7' >\n                        <span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_7_3_container' >\n                                    <input type='text' name='input_7.3' id='input_3_7_3' value=''   placeholder='City' aria-required='true'    \/>\n                                    <label for='input_3_7_3' id='input_3_7_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_3_7_4_container' >\n                                        <input type='text' name='input_7.4' id='input_3_7_4' value=''     placeholder='Province' aria-required='true'    \/>\n                                        <label for='input_3_7_4' id='input_3_7_4_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>State \/ Province \/ Region<\/label>\n                                      <\/span><input type='hidden' class='gform_hidden' name='input_7.6' id='input_3_7_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_9' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u2190'  \/> <input type='button' id='gform_next_button_3_9' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_3' class='gform_page' data-js='page-field-id-9' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Q01.0: In the last 14 days. Did you took the plane?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_10'>\n\t\t\t<li class='gchoice gchoice_3_10_0'>\n\t\t\t\t<input name='input_10' type='radio' value='_Oui'  id='choice_3_10_0'    \/>\n\t\t\t\t<label for='choice_3_10_0' id='label_3_10_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_10_1'>\n\t\t\t\t<input name='input_10' type='radio' value='_Non'  id='choice_3_10_1'    \/>\n\t\t\t\t<label for='choice_3_10_1' id='label_3_10_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_72\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_72'>Q01.1 Flight Date <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_72' id='input_3_72' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_3_72_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_72_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_72' class='gform_hidden' value='https:\/\/agency.securimed.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_13' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u2190'  \/> <input type='button' id='gform_next_button_3_13' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_4' class='gform_page' data-js='page-field-id-13' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_12\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Q02.0: Have you been closely in contact with someone that might have or that have been diagnosed with COVID-19? <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_12'>\n\t\t\t<li class='gchoice gchoice_3_12_0'>\n\t\t\t\t<input name='input_12' type='radio' value='_Oui'  id='choice_3_12_0'    \/>\n\t\t\t\t<label for='choice_3_12_0' id='label_3_12_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_12_1'>\n\t\t\t\t<input name='input_12' type='radio' value='_Non'  id='choice_3_12_1'    \/>\n\t\t\t\t<label for='choice_3_12_1' id='label_3_12_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_73\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_73'>Q02.1 Date of the last contact <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_73' id='input_3_73' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_3_73_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_73_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_73' class='gform_hidden' value='https:\/\/agency.securimed.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_15' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u2190'  \/> <input type='button' id='gform_next_button_3_15' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_5' class='gform_page' data-js='page-field-id-15' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_16\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Q03.0: In the last 14 days. Did someone living at the same adress then you have shown symptoms of fiever, cough, shortness of breath <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_16'>\n\t\t\t<li class='gchoice gchoice_3_16_0'>\n\t\t\t\t<input name='input_16' type='radio' value='_Oui'  id='choice_3_16_0'    \/>\n\t\t\t\t<label for='choice_3_16_0' id='label_3_16_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_16_1'>\n\t\t\t\t<input name='input_16' type='radio' value='_Non'  id='choice_3_16_1'    \/>\n\t\t\t\t<label for='choice_3_16_1' id='label_3_16_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_74\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_74'>Q03.1 Date of the first symptom observed<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_74' id='input_3_74' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_3_74_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_74_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_74' class='gform_hidden' value='https:\/\/agency.securimed.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_3_75\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_75'>Q03.2 Date of the end of the symptoms observed by the individual <\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_75' id='input_3_75' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_3_75_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_75_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_75' class='gform_hidden' value='https:\/\/agency.securimed.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_19' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u2190'  \/> <input type='button' id='gform_next_button_3_19' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_6' class='gform_page' data-js='page-field-id-19' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Q04.0 In which age group are you?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_20'>\n\t\t\t<li class='gchoice gchoice_3_20_0'>\n\t\t\t\t<input name='input_20' type='radio' value='_70ans'  id='choice_3_20_0'    \/>\n\t\t\t\t<label for='choice_3_20_0' id='label_3_20_0' class='gform-field-label gform-field-label--type-inline'>70 years and over<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_20_1'>\n\t\t\t\t<input name='input_20' type='radio' value='_60ans69'  id='choice_3_20_1'    \/>\n\t\t\t\t<label for='choice_3_20_1' id='label_3_20_1' class='gform-field-label gform-field-label--type-inline'>60 to 69 years old<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_20_2'>\n\t\t\t\t<input name='input_20' type='radio' value='_60ans'  id='choice_3_20_2'    \/>\n\t\t\t\t<label for='choice_3_20_2' id='label_3_20_2' class='gform-field-label gform-field-label--type-inline'>Less then 60 years old<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_71' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u2190'  \/> <input type='button' id='gform_next_button_3_71' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_7' class='gform_page' data-js='page-field-id-71' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_21\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_21'>Q05.0: How tall are you?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_3_21' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_22\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_22'>Q06.0 What is you weight?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_3_22' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_24' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u2190'  \/> <input type='button' id='gform_next_button_3_24' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_8' class='gform_page' data-js='page-field-id-24' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Q07.0 Do you have a lung disease?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_23'>\n\t\t\t<li class='gchoice gchoice_3_23_0'>\n\t\t\t\t<input name='input_23' type='radio' value='_Oui'  id='choice_3_23_0'    \/>\n\t\t\t\t<label for='choice_3_23_0' id='label_3_23_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_23_1'>\n\t\t\t\t<input name='input_23' type='radio' value='_Non'  id='choice_3_23_1'    \/>\n\t\t\t\t<label for='choice_3_23_1' id='label_3_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_25\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_25'>Q07.1 Clarifications <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_25' id='input_3_25' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_26' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u2190'  \/> <input type='button' id='gform_next_button_3_26' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_9' class='gform_page' data-js='page-field-id-26' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_27\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Q08.0 Do you smoke?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_27'>\n\t\t\t<li class='gchoice gchoice_3_27_0'>\n\t\t\t\t<input name='input_27' type='radio' value='_Oui'  id='choice_3_27_0'    \/>\n\t\t\t\t<label for='choice_3_27_0' id='label_3_27_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_27_1'>\n\t\t\t\t<input name='input_27' type='radio' value='_Non'  id='choice_3_27_1'    \/>\n\t\t\t\t<label for='choice_3_27_1' id='label_3_27_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_28\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_28'>Q08.1 Do you cough frequently?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_3_28' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_29' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u2190'  \/> <input type='button' id='gform_next_button_3_29' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_10' class='gform_page' data-js='page-field-id-29' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_10' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Q09.0: Do you have asthma?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_30'>\n\t\t\t<li class='gchoice gchoice_3_30_0'>\n\t\t\t\t<input name='input_30' type='radio' value='_Oui'  id='choice_3_30_0'    \/>\n\t\t\t\t<label for='choice_3_30_0' id='label_3_30_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_30_1'>\n\t\t\t\t<input name='input_30' type='radio' value='_Non'  id='choice_3_30_1'    \/>\n\t\t\t\t<label for='choice_3_30_1' id='label_3_30_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_31\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_31'>Q09.1 Clarifications<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_31' id='input_3_31' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_32' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u2190'  \/> <input type='button' id='gform_next_button_3_32' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_11' class='gform_page' data-js='page-field-id-32' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_11' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_33\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Q10.0 Are you immunosupressed or dou you take immunospresive drugs?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_33'>\n\t\t\t<li class='gchoice gchoice_3_33_0'>\n\t\t\t\t<input name='input_33' type='radio' value='_Oui'  id='choice_3_33_0'    \/>\n\t\t\t\t<label for='choice_3_33_0' id='label_3_33_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_33_1'>\n\t\t\t\t<input name='input_33' type='radio' value='_Non'  id='choice_3_33_1'    \/>\n\t\t\t\t<label for='choice_3_33_1' id='label_3_33_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_34\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_34'>Q10.1 Precision<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_34' id='input_3_34' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_35' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u2190'  \/> <input type='button' id='gform_next_button_3_35' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_12' class='gform_page' data-js='page-field-id-35' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_12' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Q11.0 Do you have a heart disease ( heart problems, stroke)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_36'>\n\t\t\t<li class='gchoice gchoice_3_36_0'>\n\t\t\t\t<input name='input_36' type='radio' value='_Oui'  id='choice_3_36_0'    \/>\n\t\t\t\t<label for='choice_3_36_0' id='label_3_36_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_36_1'>\n\t\t\t\t<input name='input_36' type='radio' value='_Non'  id='choice_3_36_1'    \/>\n\t\t\t\t<label for='choice_3_36_1' id='label_3_36_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_37\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_37'>Q10.1 Clarifications<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_37' id='input_3_37' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_38' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u2190'  \/> <input type='button' id='gform_next_button_3_38' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_13' class='gform_page' data-js='page-field-id-38' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_13' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_39\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Q12.0 Do you suffer from high blood pressure <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_39'>\n\t\t\t<li class='gchoice gchoice_3_39_0'>\n\t\t\t\t<input name='input_39' type='radio' value='_Non'  id='choice_3_39_0'    \/>\n\t\t\t\t<label for='choice_3_39_0' id='label_3_39_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_39_1'>\n\t\t\t\t<input name='input_39' type='radio' value='_Oui_je_ne_prends_pas_de_medicament_seulement_une_gestion_avec_la_nourriture'  id='choice_3_39_1'    \/>\n\t\t\t\t<label for='choice_3_39_1' id='label_3_39_1' class='gform-field-label gform-field-label--type-inline'>Yes, I don't  take any drug, i control the disease with foods<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_39_2'>\n\t\t\t\t<input name='input_39' type='radio' value='_Oui_je_prends_seulement_1_medicament_pour_controler_la_maladie'  id='choice_3_39_2'    \/>\n\t\t\t\t<label for='choice_3_39_2' id='label_3_39_2' class='gform-field-label gform-field-label--type-inline'>Yes, I take only one type of drug to control the disease<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_39_3'>\n\t\t\t\t<input name='input_39' type='radio' value='Oui_je_prends_plusieurs_medicaments_pour_controler_la_maladie'  id='choice_3_39_3'    \/>\n\t\t\t\t<label for='choice_3_39_3' id='label_3_39_3' class='gform-field-label gform-field-label--type-inline'>Yes, i take drugs to control the disease<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_40' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u2190'  \/> <input type='button' id='gform_next_button_3_40' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_14' class='gform_page' data-js='page-field-id-40' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_14' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_41\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Q13.0 Do you have a current or recent cancer?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_41'>\n\t\t\t<li class='gchoice gchoice_3_41_0'>\n\t\t\t\t<input name='input_41' type='radio' value='_Oui'  id='choice_3_41_0'    \/>\n\t\t\t\t<label for='choice_3_41_0' id='label_3_41_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_41_1'>\n\t\t\t\t<input name='input_41' type='radio' value='_Non'  id='choice_3_41_1'    \/>\n\t\t\t\t<label for='choice_3_41_1' id='label_3_41_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_42\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Q14.0 Do you have a chronic renale disease?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_42'>\n\t\t\t<li class='gchoice gchoice_3_42_0'>\n\t\t\t\t<input name='input_42' type='radio' value='_Oui'  id='choice_3_42_0'    \/>\n\t\t\t\t<label for='choice_3_42_0' id='label_3_42_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_42_1'>\n\t\t\t\t<input name='input_42' type='radio' value='_Non'  id='choice_3_42_1'    \/>\n\t\t\t\t<label for='choice_3_42_1' id='label_3_42_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Q15.0 Do you have a hepatic insufficiency?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_43'>\n\t\t\t<li class='gchoice gchoice_3_43_0'>\n\t\t\t\t<input name='input_43' type='radio' value='_Oui'  id='choice_3_43_0'    \/>\n\t\t\t\t<label for='choice_3_43_0' id='label_3_43_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_43_1'>\n\t\t\t\t<input name='input_43' type='radio' value='_Non'  id='choice_3_43_1'    \/>\n\t\t\t\t<label for='choice_3_43_1' id='label_3_43_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_44' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u2190'  \/> <input type='button' id='gform_next_button_3_44' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_15' class='gform_page' data-js='page-field-id-44' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_15' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_45\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Q16.1 In the last 14 days. Did you got or did you have fiever?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_45'>\n\t\t\t<li class='gchoice gchoice_3_45_0'>\n\t\t\t\t<input name='input_45' type='radio' value='_Oui'  id='choice_3_45_0'    \/>\n\t\t\t\t<label for='choice_3_45_0' id='label_3_45_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_45_1'>\n\t\t\t\t<input name='input_45' type='radio' value='_Non'  id='choice_3_45_1'    \/>\n\t\t\t\t<label for='choice_3_45_1' id='label_3_45_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_76\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_76'>Q16.1 Date when the first symptom was observed<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_76' id='input_3_76' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_3_76_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_76_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_76' class='gform_hidden' value='https:\/\/agency.securimed.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_3_77\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_77'>Q16.2 End date of the last symptom observed<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_77' id='input_3_77' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_3_77_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_77_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_77' class='gform_hidden' value='https:\/\/agency.securimed.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_48' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u2190'  \/> <input type='button' id='gform_next_button_3_48' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_16' class='gform_page' data-js='page-field-id-48' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_16' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_49\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Q17.0 Since the beggining of march . Did you had one of the following symptoms ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_49'><li class='gchoice gchoice_3_49_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.1' type='checkbox'  value='_Non'  id='choice_3_49_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_49_1' id='label_3_49_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_49_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.2' type='checkbox'  value='_Toux'  id='choice_3_49_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_49_2' id='label_3_49_2' class='gform-field-label gform-field-label--type-inline'>Cough (except smoker ) <\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_49_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.3' type='checkbox'  value='_Expectorations'  id='choice_3_49_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_49_3' id='label_3_49_3' class='gform-field-label gform-field-label--type-inline'>Expectorations (sputum) except smoker<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_49_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.4' type='checkbox'  value='_Maux_gorge'  id='choice_3_49_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_49_4' id='label_3_49_4' class='gform-field-label gform-field-label--type-inline'>Sore throat<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_78\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_78'>Q17.1 Date when the first symptom was observed<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_78' id='input_3_78' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_3_78_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_78_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_78' class='gform_hidden' value='https:\/\/agency.securimed.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_3_79\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_79'>Q17.2 End date of the last symptom observe<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_79' id='input_3_79' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_3_79_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_79_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_79' class='gform_hidden' value='https:\/\/agency.securimed.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_53' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u2190'  \/> <input type='button' id='gform_next_button_3_53' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_17' class='gform_page' data-js='page-field-id-53' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_17' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_52\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Q18.1 In the last 14 days did you had?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_52'><li class='gchoice gchoice_3_52_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.1' type='checkbox'  value='_Non'  id='choice_3_52_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_52_1' id='label_3_52_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_52_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.2' type='checkbox'  value='_Difficulte_respirer'  id='choice_3_52_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_52_2' id='label_3_52_2' class='gform-field-label gform-field-label--type-inline'>Breathing difficulty<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_52_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.3' type='checkbox'  value='_Douleur_poitrine'  id='choice_3_52_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_52_3' id='label_3_52_3' class='gform-field-label gform-field-label--type-inline'>Chest pain <\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_52_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.4' type='checkbox'  value='_Essoufflement'  id='choice_3_52_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_52_4' id='label_3_52_4' class='gform-field-label gform-field-label--type-inline'>Shortness of breath <\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_52_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.5' type='checkbox'  value='_Difficulte_allonge'  id='choice_3_52_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_52_5' id='label_3_52_5' class='gform-field-label gform-field-label--type-inline'>Difficulty to lay down because og breathing difficulty <\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_80\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_80'>Q18.1 Date when the first symptom was observe<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_80' id='input_3_80' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_3_80_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_80_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_80' class='gform_hidden' value='https:\/\/agency.securimed.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_3_81\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_81'>Q18.2 End date of the last symptom<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_81' id='input_3_81' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_3_81_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_81_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_81' class='gform_hidden' value='https:\/\/agency.securimed.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_58' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u2190'  \/> <input type='button' id='gform_next_button_3_58' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_18' class='gform_page' data-js='page-field-id-58' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_18' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_60\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Q19.0 Since the begining of march did you have flu symptoms , if so which?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_60'><li class='gchoice gchoice_3_60_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.1' type='checkbox'  value='_Non'  id='choice_3_60_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_60_1' id='label_3_60_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_60_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.2' type='checkbox'  value='_Baisse_appetit'  id='choice_3_60_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_60_2' id='label_3_60_2' class='gform-field-label gform-field-label--type-inline'>Decreased appetite<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_60_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.3' type='checkbox'  value='_Douleurs_musculaires'  id='choice_3_60_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_60_3' id='label_3_60_3' class='gform-field-label gform-field-label--type-inline'>Muscle pain, abnormal fatigue <\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_60_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.4' type='checkbox'  value='_Congestion'  id='choice_3_60_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_60_4' id='label_3_60_4' class='gform-field-label gform-field-label--type-inline'>Congestion<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_60_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.5' type='checkbox'  value='_Maux_tetes'  id='choice_3_60_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_60_5' id='label_3_60_5' class='gform-field-label gform-field-label--type-inline'>Headaches<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_60_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.6' type='checkbox'  value='_Nausees_vomissements'  id='choice_3_60_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_60_6' id='label_3_60_6' class='gform-field-label gform-field-label--type-inline'>Nausea, vomiting <\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_60_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.7' type='checkbox'  value='_Diarrhees'  id='choice_3_60_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_60_7' id='label_3_60_7' class='gform-field-label gform-field-label--type-inline'>Diarrhea<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_82\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_82'>Q19.1 Date when the first symptom was observe<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_82' id='input_3_82' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_3_82_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_82_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_82' class='gform_hidden' value='https:\/\/agency.securimed.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_3_83\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_83'>Q19.2 End date of last symptoms<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_83' id='input_3_83' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_3_83_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_83_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_83' class='gform_hidden' value='https:\/\/agency.securimed.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_61' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u2190'  \/> <input type='button' id='gform_next_button_3_61' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_19' class='gform_page' data-js='page-field-id-61' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_19' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_63\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Q20.0 Since the beginning of March, did you had symptoms of anosmia (lost of taste and\/or smell ) <\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_63'>\n\t\t\t<li class='gchoice gchoice_3_63_0'>\n\t\t\t\t<input name='input_63' type='radio' value='_Oui'  id='choice_3_63_0'    \/>\n\t\t\t\t<label for='choice_3_63_0' id='label_3_63_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_63_1'>\n\t\t\t\t<input name='input_63' type='radio' value='_Non'  id='choice_3_63_1'    \/>\n\t\t\t\t<label for='choice_3_63_1' id='label_3_63_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_84\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_84'>Q20.1 Day when the first symptom was observe<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_84' id='input_3_84' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_3_84_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_84_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_84' class='gform_hidden' value='https:\/\/agency.securimed.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_3_85\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_85'>Q20.0 Day when last symptoms where observe<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_85' id='input_3_85' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_3_85_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_85_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_85' class='gform_hidden' value='https:\/\/agency.securimed.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_65' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u2190'  \/> <input type='button' id='gform_next_button_3_65' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_20' class='gform_page' data-js='page-field-id-65' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_20' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_66\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Q21.0 Since the beggining of March did you have the following symptoms ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_66'><li class='gchoice gchoice_3_66_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.1' type='checkbox'  value='_Non'  id='choice_3_66_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_66_1' id='label_3_66_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_66_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.2' type='checkbox'  value='_Etre_confus'  id='choice_3_66_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_66_2' id='label_3_66_2' class='gform-field-label gform-field-label--type-inline'>To be confused<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_66_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.3' type='checkbox'  value='_Perte_connaissance'  id='choice_3_66_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_66_3' id='label_3_66_3' class='gform-field-label gform-field-label--type-inline'>Lost of consciousness<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_86\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_86'>Q21.1 Date of the first symptoms observe?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_86' id='input_3_86' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_3_86_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_86_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_86' class='gform_hidden' value='https:\/\/agency.securimed.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_3_87\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_87'>Q21.2 Symptoms end date ?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_87' id='input_3_87' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_3_87_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_87_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_87' class='gform_hidden' value='https:\/\/agency.securimed.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_3_69' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u2190'  \/> <input type='button' id='gform_next_button_3_69' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_3_21' class='gform_page' data-js='page-field-id-69' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_3_21' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_88\" class=\"gfield gfield--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><b>Consent<\/b><\/p>\r\n<ul>\r\n<li> By signing, I authorize the Medical Clinic to share with the Requester the report based on my answers and indications, including the conclusions, as well as all the information about my state of health.<\/li>\r\n<li> I acknowledge that my answers will serve to identify my state of health in connection with the COVID-19, as of today and a risk assessment of contagion will be carried out according to the guidelines of the Public Health. I acknowledge that giving false or misleading information could cause the Claimant to take action.<\/li>\r\n<\/ul><\/li><li id=\"field_3_70\" class=\"gfield gfield--type-signature gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_70'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class=\"ginput_container ginput_container_signature\"><input type='hidden' value='' name='input_70' id='input_3_70_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_3_70_Container' class='gfield_signature_container' style='height:180px; width:300px; ' ><canvas id=\"input_3_70\" width=\"300\" height=\"180\" style=\"border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/agency.securimed.ca\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;\" tabindex=\"0\" aria-label=\"Signature pad\" ><\/canvas><\/div><div id='input_3_70_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id='input_3_70_resetbutton' 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