{"id":7572,"date":"2024-02-05T12:50:37","date_gmt":"2024-02-05T12:50:37","guid":{"rendered":"https:\/\/www.truthforhealth.org\/?page_id=7572"},"modified":"2024-08-08T14:48:58","modified_gmt":"2024-08-08T14:48:58","slug":"vaxdamage-diagnostics","status":"publish","type":"page","link":"https:\/\/www.truthforhealth.org\/es\/vaxdamage-diagnostics\/","title":{"rendered":"Vaccine Damage Diagnostics"},"content":{"rendered":"<div class=\"wpforms-container wpforms-container-full wpforms-container-save-resume\" id=\"wpforms-4176\"><form id=\"wpforms-form-4176\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"4176\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/es\/wp-json\/wp\/v2\/pages\/7572\" data-token=\"cabceb3c6e61b48cd64c66f9bc14471e\" data-token-time=\"1791794755\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-page-indicator progress\" data-indicator=\"progress\" data-indicator-color=\"#99158c\" data-scroll=\"1\"><span class=\"wpforms-page-indicator-page-title\" data-page-1-title=\"Contact Info &amp; Consent\" data-page-2-title=\"Vaccine Center &amp; Insurance Information\" data-page-3-title=\"COVID History &amp; Shot Information\" data-page-4-title=\"Symptom Onset &amp; Known Allergies\" data-page-5-title=\"Medical Conditions\" data-page-6-title=\"Medications\" data-page-7-title=\"General Symptoms\" data-page-8-title=\"Symptoms: Head, Eyes, Ears, Nose, Mouth and Throat\" data-page-9-title=\"Symptoms: Continued\" data-page-10-title=\"Reproductive Symptoms\" data-page-11-title=\"Musculoskeletal &amp; Skin Symptoms\" data-page-12-title=\"Neurological Symptoms\" data-page-13-title=\"Physiological Changes\" data-page-14-title=\"Additional Comments\">Contact Info &amp; Consent<\/span><span class=\"wpforms-page-indicator-page-title-sep\" > - <\/span><span class=\"wpforms-page-indicator-steps\">Step <span class=\"wpforms-page-indicator-steps-current\">1<\/span> of 14<\/span><div class=\"wpforms-page-indicator-page-progress-wrap\"><div class=\"wpforms-page-indicator-page-progress\" style=\"width:7.1428571428571%;background-color:#99158c\"><\/div><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \" data-page=\"1\"><div id=\"wpforms-4176-field_100-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"100\"><\/div><div id=\"wpforms-4176-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"1\"><label class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-4176-field_1\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][1][first]\" required><label for=\"wpforms-4176-field_1\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-4176-field_1-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][1][last]\" required><label for=\"wpforms-4176-field_1-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-4176-field_2-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_2\">Date<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4176-field_2\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][2][date]\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-4176-field_3-container\" class=\"wpforms-field wpforms-field-number\" data-field-type=\"number\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_3\">Age<\/label><input type=\"number\" id=\"wpforms-4176-field_3\" class=\"wpforms-field-medium\" name=\"wpforms[fields][3]\" step=\"any\" ><\/div><div id=\"wpforms-4176-field_4-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_4\">Date of Birth<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4176-field_4\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][4][date]\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-4176-field_6-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_6\">Sex<\/label><select id=\"wpforms-4176-field_6\" class=\"wpforms-field-medium\" name=\"wpforms[fields][6]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Select Response<\/option><option value=\"Male\"  class=\"choice-1 depth-1\"  >Male<\/option><option value=\"Female\"  class=\"choice-2 depth-1\"  >Female<\/option><\/select><\/div><div id=\"wpforms-4176-field_7-container\" class=\"wpforms-field wpforms-field-email\" data-field-type=\"email\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_7\">Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-4176-field_7\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][7]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-4176-field_8-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_8\">Best Contact Number<\/label><input type=\"tel\" id=\"wpforms-4176-field_8\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][8]\" aria-label=\"Best Contact Number\" ><\/div><div id=\"wpforms-4176-field_90-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"90\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_90\">Have you sought legal counsel for your vaccine injury?<\/label><select id=\"wpforms-4176-field_90\" class=\"wpforms-field-medium\" name=\"wpforms[fields][90]\"><option value=\"No\"  class=\"choice-2 depth-1\"  >No<\/option><option value=\"Yes\"  class=\"choice-1 depth-1\"  >Yes<\/option><\/select><\/div><div id=\"wpforms-4176-field_91-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"91\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_91\">Do you feel your vaccine injury is something that should be pursued legally?<\/label><select id=\"wpforms-4176-field_91\" class=\"wpforms-field-medium\" name=\"wpforms[fields][91]\"><option value=\"Yes\"  class=\"choice-1 depth-1\"  >Yes<\/option><option value=\"No\"  class=\"choice-2 depth-1\"  >No<\/option><\/select><\/div><div id=\"wpforms-4176-field_92-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"92\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_92\">May our Truth for Health Foundation team contact you about your vaccine injury?<\/label><select id=\"wpforms-4176-field_92\" class=\"wpforms-field-medium\" name=\"wpforms[fields][92]\"><option value=\"Yes\"  class=\"choice-1 depth-1\"  >Yes<\/option><option value=\"No\"  class=\"choice-2 depth-1\"  >No<\/option><\/select><\/div><div id=\"wpforms-4176-field_99-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"99\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><span class=\"wpforms-page-button-group\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"1\" data-formid=\"4176\" disabled>Next<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.truthforhealth.org\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-page-button-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/span><a href=\"#\" class=\"wpforms-save-resume-button\"><span>Save and Continue Later<\/span><\/a><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2  \" data-page=\"2\" style=\"display:none;\"><div id=\"wpforms-4176-field_97-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"97\"><label class=\"wpforms-field-label\">Please provide the type of facility where your vaccine shot (s) were administered (Check ALL that apply if you have had more than one shot):<\/label><ul id=\"wpforms-4176-field_97\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_97_1\" name=\"wpforms[fields][97][]\" value=\"Pharmacy\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_97_1\">Pharmacy<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_97_2\" name=\"wpforms[fields][97][]\" value=\"Hospital\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_97_2\">Hospital<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_97_3\" name=\"wpforms[fields][97][]\" value=\"Doctor&#039;s Office\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_97_3\">Doctor's Office<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_97_4\" name=\"wpforms[fields][97][]\" value=\"Grocery store\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_97_4\">Grocery store<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_97_5\" name=\"wpforms[fields][97][]\" value=\"Church\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_97_5\">Church<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_97_6\" name=\"wpforms[fields][97][]\" value=\"Vaccination Drive-through program\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_97_6\">Vaccination Drive-through program<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_97_7\" name=\"wpforms[fields][97][]\" value=\"Place of Employment\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_97_7\">Place of Employment<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_97_8\" name=\"wpforms[fields][97][]\" value=\"Other (List below)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_97_8\">Other (List below)<\/label><\/li><\/ul><\/div><div id=\"wpforms-4176-field_42-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_42\">Please provide names of the facility or facilities where your vaccine shot(s) were administered:<\/label><textarea id=\"wpforms-4176-field_42\" class=\"wpforms-field-medium\" name=\"wpforms[fields][42]\" ><\/textarea><\/div><div id=\"wpforms-4176-field_93-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"93\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_93\">Did the facility where your vaccine was administered ask you to show your INSURANCE CARD?<\/label><select id=\"wpforms-4176-field_93\" class=\"wpforms-field-medium\" name=\"wpforms[fields][93]\"><option value=\"Yes\"  class=\"choice-1 depth-1\"  >Yes<\/option><option value=\"No\"  class=\"choice-2 depth-1\"  >No<\/option><\/select><\/div><div id=\"wpforms-4176-field_52-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"52\"><label class=\"wpforms-field-label\">What type of insurance do you have?<\/label><ul id=\"wpforms-4176-field_52\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_52_1\" name=\"wpforms[fields][52][]\" value=\"Medicaid\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_52_1\">Medicaid<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_52_2\" name=\"wpforms[fields][52][]\" value=\"Medicare\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_52_2\">Medicare<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_52_3\" name=\"wpforms[fields][52][]\" value=\"Tri-Care\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_52_3\">Tri-Care<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_52_4\" name=\"wpforms[fields][52][]\" value=\"VA (Veterans Administration)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_52_4\">VA (Veterans Administration)<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_52_5\" name=\"wpforms[fields][52][]\" value=\"Private Insurance (List Carrier Below)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_52_5\">Private Insurance (List Carrier Below)<\/label><\/li><\/ul><\/div><div id=\"wpforms-4176-field_98-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"98\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_98\">Please provide name of Private Insurance Carrier (if any):<\/label><textarea id=\"wpforms-4176-field_98\" class=\"wpforms-field-medium\" name=\"wpforms[fields][98]\" ><\/textarea><\/div><div id=\"wpforms-4176-field_41-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"41\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_41\">Is the filer the same as the injured?<\/label><select id=\"wpforms-4176-field_41\" class=\"wpforms-field-medium\" name=\"wpforms[fields][41]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Select Response<\/option><option value=\"Yes\"  class=\"choice-1 depth-1\"  >Yes<\/option><option value=\"No\"  class=\"choice-2 depth-1\"  >No<\/option><\/select><\/div><div id=\"wpforms-4176-field_96-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"96\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_96\">If not, please provide your name, contact info (copy)<\/label><textarea id=\"wpforms-4176-field_96\" class=\"wpforms-field-medium\" name=\"wpforms[fields][96]\" ><\/textarea><\/div><div id=\"wpforms-4176-field_102-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"102\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><span class=\"wpforms-page-button-group\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"2\" data-formid=\"4176\" disabled>Next<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.truthforhealth.org\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-page-button-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/span><a href=\"#\" class=\"wpforms-save-resume-button\"><span>Save and Continue Later<\/span><\/a><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-3  \" data-page=\"3\" style=\"display:none;\"><div id=\"wpforms-4176-field_67-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"67\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_67\">Did you have COVID confirmed prior to taking the shot?<\/label><select id=\"wpforms-4176-field_67\" class=\"wpforms-field-medium\" name=\"wpforms[fields][67]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Select Response<\/option><option value=\"Yes\"  class=\"choice-1 depth-1\"  >Yes<\/option><option value=\"No\"  class=\"choice-2 depth-1\"  >No<\/option><\/select><\/div><div id=\"wpforms-4176-field_68-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"68\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_68\">Did you have suspected COVID prior to taking the shot?<\/label><select id=\"wpforms-4176-field_68\" class=\"wpforms-field-medium\" name=\"wpforms[fields][68]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Select Response<\/option><option value=\"Yes\"  class=\"choice-1 depth-1\"  >Yes<\/option><option value=\"No\"  class=\"choice-2 depth-1\"  >No<\/option><\/select><\/div><div id=\"wpforms-4176-field_69-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"69\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_69\">Did you have COVID after taking the shot?<\/label><select id=\"wpforms-4176-field_69\" class=\"wpforms-field-medium\" name=\"wpforms[fields][69]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Select Response<\/option><option value=\"Yes\"  class=\"choice-1 depth-1\"  >Yes<\/option><option value=\"No\"  class=\"choice-2 depth-1\"  >No<\/option><\/select><\/div><div id=\"wpforms-4176-field_43-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_43\">Reason for taking the shot<\/label><select id=\"wpforms-4176-field_43\" class=\"wpforms-field-medium\" name=\"wpforms[fields][43]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Select Response<\/option><option value=\"Employer mandate\"  class=\"choice-1 depth-1\"  >Employer mandate<\/option><option value=\"Military mandate\"  class=\"choice-2 depth-1\"  >Military mandate<\/option><option value=\"Desire to prevent infection\"  class=\"choice-3 depth-1\"  >Desire to prevent infection<\/option><option value=\"Desire to protect others\"  class=\"choice-4 depth-1\"  >Desire to protect others<\/option><option value=\"Travel\"  class=\"choice-5 depth-1\"  >Travel<\/option><option value=\"Family pressure\"  class=\"choice-6 depth-1\"  >Family pressure<\/option><option value=\"Social pressure\"  class=\"choice-7 depth-1\"  >Social pressure<\/option><option value=\"College\/University requirement\"  class=\"choice-9 depth-1\"  >College\/University requirement<\/option><option value=\"Nursing home requirement\"  class=\"choice-10 depth-1\"  >Nursing home requirement<\/option><option value=\"Assisted Living requirement\"  class=\"choice-11 depth-1\"  >Assisted Living requirement<\/option><option value=\"Retirement Community requirement\"  class=\"choice-12 depth-1\"  >Retirement Community requirement<\/option><option value=\"Other\"  class=\"choice-8 depth-1\"  >Other<\/option><\/select><\/div><div id=\"wpforms-4176-field_44-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"44\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_44\">If other please provide reason<\/label><input type=\"text\" id=\"wpforms-4176-field_44\" class=\"wpforms-field-medium\" name=\"wpforms[fields][44]\" ><\/div><div id=\"wpforms-4176-field_76-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"76\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_76\">Shot 1 type <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-4176-field_76\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][76]\" required=\"required\"><option value=\"Pfizer\"  class=\"choice-1 depth-1\"  >Pfizer<\/option><option value=\"Moderna\"  class=\"choice-2 depth-1\"  >Moderna<\/option><option value=\"Johnson &amp; Johnson\"  class=\"choice-3 depth-1\"  >Johnson &amp; Johnson<\/option><option value=\"Astra Zeneca\"  class=\"choice-4 depth-1\"  >Astra Zeneca<\/option><option value=\"Sinovac\"  class=\"choice-5 depth-1\"  >Sinovac<\/option><option value=\"Covaxin\"  class=\"choice-6 depth-1\"  >Covaxin<\/option><option value=\"Covishield\"  class=\"choice-7 depth-1\"  >Covishield<\/option><\/select><\/div><div id=\"wpforms-4176-field_46-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"46\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_46\">Shot 1 date received (if known)<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4176-field_46\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][46][date]\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-4176-field_49-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"49\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_49\">Shot 1 Lot number (if known)<\/label><input type=\"text\" id=\"wpforms-4176-field_49\" class=\"wpforms-field-medium\" name=\"wpforms[fields][49]\" ><\/div><div id=\"wpforms-4176-field_77-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"77\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_77\">Shot 2 type (if taken)<\/label><select id=\"wpforms-4176-field_77\" class=\"wpforms-field-medium\" name=\"wpforms[fields][77]\"><option value=\"Pfizer\"  class=\"choice-1 depth-1\"  >Pfizer<\/option><option value=\"Moderna\"  class=\"choice-2 depth-1\"  >Moderna<\/option><option value=\"Johnson &amp; Johnson\"  class=\"choice-3 depth-1\"  >Johnson &amp; Johnson<\/option><option value=\"Astra Zeneca\"  class=\"choice-4 depth-1\"  >Astra Zeneca<\/option><option value=\"Sinovac\"  class=\"choice-5 depth-1\"  >Sinovac<\/option><option value=\"Covaxin\"  class=\"choice-6 depth-1\"  >Covaxin<\/option><option value=\"Covishield\"  class=\"choice-7 depth-1\"  >Covishield<\/option><\/select><\/div><div id=\"wpforms-4176-field_47-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"47\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_47\">Shot 2 date received (if known)<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4176-field_47\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][47][date]\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-4176-field_50-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"50\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_50\">Shot 2 Lot number (if known)<\/label><input type=\"text\" id=\"wpforms-4176-field_50\" class=\"wpforms-field-medium\" name=\"wpforms[fields][50]\" ><\/div><div id=\"wpforms-4176-field_78-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"78\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_78\">Shot 3 type (if taken)<\/label><select id=\"wpforms-4176-field_78\" class=\"wpforms-field-medium\" name=\"wpforms[fields][78]\"><option value=\"Pfizer\"  class=\"choice-1 depth-1\"  >Pfizer<\/option><option value=\"Moderna\"  class=\"choice-2 depth-1\"  >Moderna<\/option><option value=\"Johnson &amp; Johnson\"  class=\"choice-3 depth-1\"  >Johnson &amp; Johnson<\/option><option value=\"Astra Zeneca\"  class=\"choice-4 depth-1\"  >Astra Zeneca<\/option><option value=\"Sinovac\"  class=\"choice-5 depth-1\"  >Sinovac<\/option><option value=\"Covaxin\"  class=\"choice-6 depth-1\"  >Covaxin<\/option><option value=\"Covishield\"  class=\"choice-7 depth-1\"  >Covishield<\/option><\/select><\/div><div id=\"wpforms-4176-field_48-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"48\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_48\">Shot 3 date received (if known)<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4176-field_48\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][48][date]\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-4176-field_51-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"51\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_51\">Shot 3 Lot number (if known)<\/label><input type=\"text\" id=\"wpforms-4176-field_51\" class=\"wpforms-field-medium\" name=\"wpforms[fields][51]\" ><\/div><div id=\"wpforms-4176-field_79-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"79\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_79\">Shot 4 type (if taken)<\/label><select id=\"wpforms-4176-field_79\" class=\"wpforms-field-medium\" name=\"wpforms[fields][79]\"><option value=\"Pfizer\"  class=\"choice-1 depth-1\"  >Pfizer<\/option><option value=\"Moderna\"  class=\"choice-2 depth-1\"  >Moderna<\/option><option value=\"Johnson &amp; Johnson\"  class=\"choice-3 depth-1\"  >Johnson &amp; Johnson<\/option><option value=\"Astra Zeneca\"  class=\"choice-4 depth-1\"  >Astra Zeneca<\/option><option value=\"Sinovac\"  class=\"choice-5 depth-1\"  >Sinovac<\/option><option value=\"Covaxin\"  class=\"choice-6 depth-1\"  >Covaxin<\/option><option value=\"Covishield\"  class=\"choice-7 depth-1\"  >Covishield<\/option><\/select><\/div><div id=\"wpforms-4176-field_70-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"70\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_70\">Shot 4 date received (if known)<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4176-field_70\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][70][date]\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-4176-field_73-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"73\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_73\">Shot 4 Lot number (if known)<\/label><input type=\"text\" id=\"wpforms-4176-field_73\" class=\"wpforms-field-medium\" name=\"wpforms[fields][73]\" ><\/div><div id=\"wpforms-4176-field_80-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"80\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_80\">Shot 5 type (if taken)<\/label><select id=\"wpforms-4176-field_80\" class=\"wpforms-field-medium\" name=\"wpforms[fields][80]\"><option value=\"Pfizer\"  class=\"choice-1 depth-1\"  >Pfizer<\/option><option value=\"Moderna\"  class=\"choice-2 depth-1\"  >Moderna<\/option><option value=\"Johnson &amp; Johnson\"  class=\"choice-3 depth-1\"  >Johnson &amp; Johnson<\/option><option value=\"Astra Zeneca\"  class=\"choice-4 depth-1\"  >Astra Zeneca<\/option><option value=\"Sinovac\"  class=\"choice-5 depth-1\"  >Sinovac<\/option><option value=\"Covaxin\"  class=\"choice-6 depth-1\"  >Covaxin<\/option><option value=\"Covishield\"  class=\"choice-7 depth-1\"  >Covishield<\/option><\/select><\/div><div id=\"wpforms-4176-field_71-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"71\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_71\">Shot 5 date received (if known)<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4176-field_71\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][71][date]\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-4176-field_74-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"74\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_74\">Shot 5 Lot number (if known)<\/label><input type=\"text\" id=\"wpforms-4176-field_74\" class=\"wpforms-field-medium\" name=\"wpforms[fields][74]\" ><\/div><div id=\"wpforms-4176-field_81-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"81\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_81\">Shot 6 type (if taken)<\/label><select id=\"wpforms-4176-field_81\" class=\"wpforms-field-medium\" name=\"wpforms[fields][81]\"><option value=\"Pfizer\"  class=\"choice-1 depth-1\"  >Pfizer<\/option><option value=\"Moderna\"  class=\"choice-2 depth-1\"  >Moderna<\/option><option value=\"Johnson &amp; Johnson\"  class=\"choice-3 depth-1\"  >Johnson &amp; Johnson<\/option><option value=\"Astra Zeneca\"  class=\"choice-4 depth-1\"  >Astra Zeneca<\/option><option value=\"Sinovac\"  class=\"choice-5 depth-1\"  >Sinovac<\/option><option value=\"Covaxin\"  class=\"choice-6 depth-1\"  >Covaxin<\/option><option value=\"Covishield\"  class=\"choice-7 depth-1\"  >Covishield<\/option><\/select><\/div><div id=\"wpforms-4176-field_72-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"72\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_72\">Shot 6 date received (if known)<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4176-field_72\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][72][date]\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-4176-field_75-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"75\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_75\">Shot 6 Lot number (if known)<\/label><input type=\"text\" id=\"wpforms-4176-field_75\" class=\"wpforms-field-medium\" name=\"wpforms[fields][75]\" ><\/div><div id=\"wpforms-4176-field_103-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"103\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><span class=\"wpforms-page-button-group\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"3\" data-formid=\"4176\" disabled>Next<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.truthforhealth.org\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-page-button-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/span><a href=\"#\" class=\"wpforms-save-resume-button\"><span>Save and Continue Later<\/span><\/a><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-4  \" data-page=\"4\" style=\"display:none;\"><div id=\"wpforms-4176-field_12-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_12\">When did your adverse event or symptoms begin?<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-4176-field_12\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][12][date]\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-4176-field_95-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"95\"><label class=\"wpforms-field-label\">Outcome of the adverse event or symptoms (check all that apply) (copy)<\/label><ul id=\"wpforms-4176-field_95\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_95_1\" name=\"wpforms[fields][95][]\" value=\"Visit to doctor or other health professional\u2019s office\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_95_1\">Visit to doctor or other health professional\u2019s office<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_95_2\" name=\"wpforms[fields][95][]\" value=\"Visit to emergency room or urgent care center\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_95_2\">Visit to emergency room or urgent care center<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_95_3\" name=\"wpforms[fields][95][]\" value=\"Hospitalization\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_95_3\">Hospitalization<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_95_4\" name=\"wpforms[fields][95][]\" value=\"Prolonged Hospitalization (COVID shot received in hospital)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_95_4\">Prolonged Hospitalization (COVID shot received in hospital)<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_95_5\" name=\"wpforms[fields][95][]\" value=\"Life threatening illness\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_95_5\">Life threatening illness<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_95_6\" name=\"wpforms[fields][95][]\" value=\"Disability or permanent damage\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_95_6\">Disability or permanent damage<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_95_7\" name=\"wpforms[fields][95][]\" value=\"Patient Died\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_95_7\">Patient Died<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_95_8\" name=\"wpforms[fields][95][]\" value=\"Congenital anomaly or birth defect\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_95_8\">Congenital anomaly or birth defect<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_95_9\" name=\"wpforms[fields][95][]\" value=\"Miscarriage or still birth\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_95_9\">Miscarriage or still birth<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_95_10\" name=\"wpforms[fields][95][]\" value=\"None of the above\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_95_10\">None of the above<\/label><\/li><\/ul><\/div><div id=\"wpforms-4176-field_14-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_14\">Are Symptoms Still Happening<\/label><select id=\"wpforms-4176-field_14\" class=\"wpforms-field-medium\" name=\"wpforms[fields][14]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Select Response<\/option><option value=\"Yes\"  class=\"choice-1 depth-1\"  >Yes<\/option><option value=\"No\"  class=\"choice-2 depth-1\"  >No<\/option><\/select><\/div><div id=\"wpforms-4176-field_53-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"53\"><label class=\"wpforms-field-label\">Known allergies to <\/label><ul id=\"wpforms-4176-field_53\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_53_1\" name=\"wpforms[fields][53][]\" value=\"Medications\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_53_1\">Medications<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_53_2\" name=\"wpforms[fields][53][]\" value=\"Polyethylene glycol\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_53_2\">Polyethylene glycol<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_53_3\" name=\"wpforms[fields][53][]\" value=\"Food\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_53_3\">Food<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_53_4\" name=\"wpforms[fields][53][]\" value=\"Environmental\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_53_4\">Environmental<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_53_5\" name=\"wpforms[fields][53][]\" value=\"Other\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_53_5\">Other<\/label><\/li><\/ul><\/div><div id=\"wpforms-4176-field_54-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"54\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_54\">Description of known allergies<\/label><textarea id=\"wpforms-4176-field_54\" class=\"wpforms-field-medium\" name=\"wpforms[fields][54]\" ><\/textarea><\/div><div id=\"wpforms-4176-field_55-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"55\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_55\">Occupation<\/label><input type=\"text\" id=\"wpforms-4176-field_55\" class=\"wpforms-field-medium\" name=\"wpforms[fields][55]\" ><\/div><div id=\"wpforms-4176-field_56-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"56\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_56\">Racial background<\/label><select id=\"wpforms-4176-field_56\" class=\"wpforms-field-medium\" name=\"wpforms[fields][56]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Select Response<\/option><option value=\"Black\"  class=\"choice-1 depth-1\"  >Black<\/option><option value=\"Hispanic\"  class=\"choice-2 depth-1\"  >Hispanic<\/option><option value=\"Caucasian\"  class=\"choice-3 depth-1\"  >Caucasian<\/option><option value=\"Asian\"  class=\"choice-4 depth-1\"  >Asian<\/option><option value=\"Native American\"  class=\"choice-5 depth-1\"  >Native American<\/option><option value=\"Other\"  class=\"choice-6 depth-1\"  >Other<\/option><\/select><\/div><div id=\"wpforms-4176-field_59-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"59\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_59\">Were you pregnant at the time of the shot<\/label><select id=\"wpforms-4176-field_59\" class=\"wpforms-field-medium\" name=\"wpforms[fields][59]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Select Response<\/option><option value=\"Yes\"  class=\"choice-1 depth-1\"  >Yes<\/option><option value=\"No\"  class=\"choice-2 depth-1\"  >No<\/option><\/select><\/div><div id=\"wpforms-4176-field_60-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"60\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_60\">Have you ever had a vaccine reaction in the past<\/label><select id=\"wpforms-4176-field_60\" class=\"wpforms-field-medium\" name=\"wpforms[fields][60]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Select Response<\/option><option value=\"Yes\"  class=\"choice-1 depth-1\"  >Yes<\/option><option value=\"No\"  class=\"choice-2 depth-1\"  >No<\/option><\/select><\/div><div id=\"wpforms-4176-field_61-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"61\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_61\">If so please specify<\/label><textarea id=\"wpforms-4176-field_61\" class=\"wpforms-field-medium\" name=\"wpforms[fields][61]\" ><\/textarea><\/div><div id=\"wpforms-4176-field_104-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"104\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><span class=\"wpforms-page-button-group\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"4\" data-formid=\"4176\" disabled>Next<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.truthforhealth.org\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-page-button-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/span><a href=\"#\" class=\"wpforms-save-resume-button\"><span>Save and Continue Later<\/span><\/a><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-5  \" data-page=\"5\" style=\"display:none;\"><div id=\"wpforms-4176-field_15-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"15\"><h3 id=\"wpforms-4176-field_15\">Medical Conditions: NEW ONSET since your COVID shot (check all that apply)<\/h3><\/div><div id=\"wpforms-4176-field_17-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"17\"><label class=\"wpforms-field-label wpforms-label-hide\">New Onset Conditions<\/label><ul id=\"wpforms-4176-field_17\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_1\" name=\"wpforms[fields][17][]\" value=\"Addison&#039;s Disease\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_1\">Addison's Disease<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_2\" name=\"wpforms[fields][17][]\" value=\"Allergies\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_2\">Allergies<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_3\" name=\"wpforms[fields][17][]\" value=\"Arrhythmias\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_3\">Arrhythmias<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_4\" name=\"wpforms[fields][17][]\" value=\"Atrial Fibrillation\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_4\">Atrial Fibrillation<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_5\" name=\"wpforms[fields][17][]\" value=\"Autoimmune vasculitis\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_5\">Autoimmune vasculitis<\/label><\/li><li class=\"choice-46 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_46\" name=\"wpforms[fields][17][]\" value=\"Bell&#039;s Palsy (facial paralysis)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_46\">Bell's Palsy (facial paralysis)<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_6\" name=\"wpforms[fields][17][]\" value=\"Bronchitis\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_6\">Bronchitis<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_7\" name=\"wpforms[fields][17][]\" value=\"Cancer\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_7\">Cancer<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_8\" name=\"wpforms[fields][17][]\" value=\"Celiac Disease (gluten intolerance)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_8\">Celiac Disease (gluten intolerance)<\/label><\/li><li class=\"choice-36 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_36\" name=\"wpforms[fields][17][]\" value=\"Chronic kidney disease\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_36\">Chronic kidney disease<\/label><\/li><li class=\"choice-47 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_47\" name=\"wpforms[fields][17][]\" value=\"Chronic Obstructive Pulmonary Disease\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_47\">Chronic Obstructive Pulmonary Disease<\/label><\/li><li class=\"choice-33 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_33\" name=\"wpforms[fields][17][]\" value=\"Congestive Heart Failure\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_33\">Congestive Heart Failure<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_9\" name=\"wpforms[fields][17][]\" value=\"Crohn&#039;s Disease\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_9\">Crohn's Disease<\/label><\/li><li class=\"choice-37 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_37\" name=\"wpforms[fields][17][]\" value=\"DVT (blood clots)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_37\">DVT (blood clots)<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_10\" name=\"wpforms[fields][17][]\" value=\"Diabetes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_10\">Diabetes<\/label><\/li><li class=\"choice-38 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_38\" name=\"wpforms[fields][17][]\" value=\"Encephalitis (brain inflammation\/headaches)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_38\">Encephalitis (brain inflammation\/headaches)<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_11\" name=\"wpforms[fields][17][]\" value=\"Epilepsy (seizures)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_11\">Epilepsy (seizures)<\/label><\/li><li class=\"choice-34 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_34\" name=\"wpforms[fields][17][]\" value=\"Heart Disease\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_34\">Heart Disease<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_12\" name=\"wpforms[fields][17][]\" value=\"Herpes Type 1\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_12\">Herpes Type 1<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_13\" name=\"wpforms[fields][17][]\" value=\"Herpes Type 2\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_13\">Herpes Type 2<\/label><\/li><li class=\"choice-39 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_39\" name=\"wpforms[fields][17][]\" value=\"HIV\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_39\">HIV<\/label><\/li><li class=\"choice-40 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_40\" name=\"wpforms[fields][17][]\" value=\"Hypertension (High Blood Pressure)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_40\">Hypertension (High Blood Pressure)<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_14\" name=\"wpforms[fields][17][]\" value=\"Inflammatory Bowel Disease\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_14\">Inflammatory Bowel Disease<\/label><\/li><li class=\"choice-41 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_41\" name=\"wpforms[fields][17][]\" value=\"Kidney disease, acute\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_41\">Kidney disease, acute<\/label><\/li><li class=\"choice-35 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_35\" name=\"wpforms[fields][17][]\" value=\"Liver Disease\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_35\">Liver Disease<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_15\" name=\"wpforms[fields][17][]\" value=\"Lupus\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_15\">Lupus<\/label><\/li><li class=\"choice-42 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_42\" name=\"wpforms[fields][17][]\" value=\"Miscarriage\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_42\">Miscarriage<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_16\" name=\"wpforms[fields][17][]\" value=\"Multiple sclerosis\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_16\">Multiple sclerosis<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_17\" name=\"wpforms[fields][17][]\" value=\"Myasthenia gravis\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_17\">Myasthenia gravis<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_18\" name=\"wpforms[fields][17][]\" value=\"Myocardial infarction (heart attack)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_18\">Myocardial infarction (heart attack)<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_19\" name=\"wpforms[fields][17][]\" value=\"Myocarditis\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_19\">Myocarditis<\/label><\/li><li class=\"choice-20 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_20\" name=\"wpforms[fields][17][]\" value=\"Osteoarthritis\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_20\">Osteoarthritis<\/label><\/li><li class=\"choice-21 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_21\" name=\"wpforms[fields][17][]\" value=\"Pericarditis\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_21\">Pericarditis<\/label><\/li><li class=\"choice-22 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_22\" name=\"wpforms[fields][17][]\" value=\"Pernicious Anemia\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_22\">Pernicious Anemia<\/label><\/li><li class=\"choice-23 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_23\" name=\"wpforms[fields][17][]\" value=\"Pneumonia\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_23\">Pneumonia<\/label><\/li><li class=\"choice-43 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_43\" name=\"wpforms[fields][17][]\" value=\"Preterm labor\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_43\">Preterm labor<\/label><\/li><li class=\"choice-24 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_24\" name=\"wpforms[fields][17][]\" value=\"Psoriasis\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_24\">Psoriasis<\/label><\/li><li class=\"choice-25 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_25\" name=\"wpforms[fields][17][]\" value=\"Psoriatic arthritis\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_25\">Psoriatic arthritis<\/label><\/li><li class=\"choice-44 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_44\" name=\"wpforms[fields][17][]\" value=\"Pulmonary embolism\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_44\">Pulmonary embolism<\/label><\/li><li class=\"choice-26 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_26\" name=\"wpforms[fields][17][]\" value=\"Rheumatoid Arthritis\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_26\">Rheumatoid Arthritis<\/label><\/li><li class=\"choice-27 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_27\" name=\"wpforms[fields][17][]\" value=\"Shingles\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_27\">Shingles<\/label><\/li><li class=\"choice-28 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_28\" name=\"wpforms[fields][17][]\" value=\"Sjogren&#039;s syndrome\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_28\">Sjogren's syndrome<\/label><\/li><li class=\"choice-45 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_45\" name=\"wpforms[fields][17][]\" value=\"Still birth\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_45\">Still birth<\/label><\/li><li class=\"choice-29 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_29\" name=\"wpforms[fields][17][]\" value=\"Stroke\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_29\">Stroke<\/label><\/li><li class=\"choice-30 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_30\" name=\"wpforms[fields][17][]\" value=\"Transient Ischemic Attacks (TIA)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_30\">Transient Ischemic Attacks (TIA)<\/label><\/li><li class=\"choice-31 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_31\" name=\"wpforms[fields][17][]\" value=\"Thyroid Disorder\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_31\">Thyroid Disorder<\/label><\/li><li class=\"choice-32 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_17_32\" name=\"wpforms[fields][17][]\" value=\"Ulcerative Colitis\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_17_32\">Ulcerative Colitis<\/label><\/li><\/ul><\/div><div id=\"wpforms-4176-field_18-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"18\"><h3 id=\"wpforms-4176-field_18\">Since the COVID shot have you had WORSENING of any of the following EXISTING medical problems?<\/h3><\/div><div id=\"wpforms-4176-field_19-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"19\"><label class=\"wpforms-field-label wpforms-label-hide\">Worsening of Existing Conditions<\/label><ul id=\"wpforms-4176-field_19\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_1\" name=\"wpforms[fields][19][]\" value=\"Addison&#039;s Disease\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_1\">Addison's Disease<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_2\" name=\"wpforms[fields][19][]\" value=\"Allergies\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_2\">Allergies<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_3\" name=\"wpforms[fields][19][]\" value=\"Arrhythmias\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_3\">Arrhythmias<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_4\" name=\"wpforms[fields][19][]\" value=\"Atrial Fibrillation\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_4\">Atrial Fibrillation<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_5\" name=\"wpforms[fields][19][]\" value=\"Autoimmune vasculitis\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_5\">Autoimmune vasculitis<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_6\" name=\"wpforms[fields][19][]\" value=\"Bronchitis\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_6\">Bronchitis<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_7\" name=\"wpforms[fields][19][]\" value=\"Cancer\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_7\">Cancer<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_8\" name=\"wpforms[fields][19][]\" value=\"Celiac Disease (gluten intolerance)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_8\">Celiac Disease (gluten intolerance)<\/label><\/li><li class=\"choice-33 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_33\" name=\"wpforms[fields][19][]\" value=\"Chronic Kidney Disease\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_33\">Chronic Kidney Disease<\/label><\/li><li class=\"choice-39 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_39\" name=\"wpforms[fields][19][]\" value=\"Chronic Obstructive Pulmonary Disease\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_39\">Chronic Obstructive Pulmonary Disease<\/label><\/li><li class=\"choice-38 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_38\" name=\"wpforms[fields][19][]\" value=\"Congestive Heart Failure\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_38\">Congestive Heart Failure<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_9\" name=\"wpforms[fields][19][]\" value=\"Crohn&#039;s Disease\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_9\">Crohn's Disease<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_10\" name=\"wpforms[fields][19][]\" value=\"Diabetes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_10\">Diabetes<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_11\" name=\"wpforms[fields][19][]\" value=\"Epilepsy (seizures)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_11\">Epilepsy (seizures)<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_12\" name=\"wpforms[fields][19][]\" value=\"Herpes Type 1\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_12\">Herpes Type 1<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_13\" name=\"wpforms[fields][19][]\" value=\"Herpes Type 2\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_13\">Herpes Type 2<\/label><\/li><li class=\"choice-34 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_34\" name=\"wpforms[fields][19][]\" value=\"HIV\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_34\">HIV<\/label><\/li><li class=\"choice-35 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_35\" name=\"wpforms[fields][19][]\" value=\"Hypertension (High Blood Pressure)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_35\">Hypertension (High Blood Pressure)<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_14\" name=\"wpforms[fields][19][]\" value=\"Inflammatory Bowel Disease\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_14\">Inflammatory Bowel Disease<\/label><\/li><li class=\"choice-37 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_37\" name=\"wpforms[fields][19][]\" value=\"Kidney disease, chronic\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_37\">Kidney disease, chronic<\/label><\/li><li class=\"choice-36 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_36\" name=\"wpforms[fields][19][]\" value=\"Liver Disease\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_36\">Liver Disease<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_15\" name=\"wpforms[fields][19][]\" value=\"Lupus\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_15\">Lupus<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_16\" name=\"wpforms[fields][19][]\" value=\"Multiple sclerosis\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_16\">Multiple sclerosis<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_17\" name=\"wpforms[fields][19][]\" value=\"Myasthenia gravis\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_17\">Myasthenia gravis<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_18\" name=\"wpforms[fields][19][]\" value=\"Myocardial infarction (heart attack)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_18\">Myocardial infarction (heart attack)<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_19\" name=\"wpforms[fields][19][]\" value=\"Myocarditis\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_19\">Myocarditis<\/label><\/li><li class=\"choice-20 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_20\" name=\"wpforms[fields][19][]\" value=\"Osteoarthritis\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_20\">Osteoarthritis<\/label><\/li><li class=\"choice-21 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_21\" name=\"wpforms[fields][19][]\" value=\"Pericarditis\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_21\">Pericarditis<\/label><\/li><li class=\"choice-22 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_22\" name=\"wpforms[fields][19][]\" value=\"Pernicious Anemia\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_22\">Pernicious Anemia<\/label><\/li><li class=\"choice-23 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_23\" name=\"wpforms[fields][19][]\" value=\"Pneumonia\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_23\">Pneumonia<\/label><\/li><li class=\"choice-24 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_24\" name=\"wpforms[fields][19][]\" value=\"Psoriasis\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_24\">Psoriasis<\/label><\/li><li class=\"choice-25 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_25\" name=\"wpforms[fields][19][]\" value=\"Psoriatic arthritis\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_25\">Psoriatic arthritis<\/label><\/li><li class=\"choice-26 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_26\" name=\"wpforms[fields][19][]\" value=\"Rheumatoid Arthritis\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_26\">Rheumatoid Arthritis<\/label><\/li><li class=\"choice-27 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_27\" name=\"wpforms[fields][19][]\" value=\"Shingles\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_27\">Shingles<\/label><\/li><li class=\"choice-28 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_28\" name=\"wpforms[fields][19][]\" value=\"Sjogren&#039;s syndrome\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_28\">Sjogren's syndrome<\/label><\/li><li class=\"choice-29 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_29\" name=\"wpforms[fields][19][]\" value=\"Stroke\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_29\">Stroke<\/label><\/li><li class=\"choice-30 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_30\" name=\"wpforms[fields][19][]\" value=\"Transient Ischemic Attacks (TIA)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_30\">Transient Ischemic Attacks (TIA)<\/label><\/li><li class=\"choice-31 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_31\" name=\"wpforms[fields][19][]\" value=\"Thyroid Disorder\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_31\">Thyroid Disorder<\/label><\/li><li class=\"choice-32 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_19_32\" name=\"wpforms[fields][19][]\" value=\"Ulcerative Colitis\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_19_32\">Ulcerative Colitis<\/label><\/li><\/ul><\/div><div id=\"wpforms-4176-field_20-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_20\">Other Conditions Not Listed<\/label><textarea id=\"wpforms-4176-field_20\" class=\"wpforms-field-medium\" name=\"wpforms[fields][20]\" ><\/textarea><\/div><div id=\"wpforms-4176-field_66-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"66\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_66\">If you developed a new cancer or recurrence of an existing cancer after the COVID shot please specify the type of cancer<\/label><input type=\"text\" id=\"wpforms-4176-field_66\" class=\"wpforms-field-medium\" name=\"wpforms[fields][66]\" ><\/div><div id=\"wpforms-4176-field_105-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"105\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><span class=\"wpforms-page-button-group\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"5\" data-formid=\"4176\" disabled>Next<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.truthforhealth.org\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-page-button-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/span><a href=\"#\" class=\"wpforms-save-resume-button\"><span>Save and Continue Later<\/span><\/a><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-6  \" data-page=\"6\" style=\"display:none;\"><div id=\"wpforms-4176-field_21-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_21\">Current Prescription Medications: LIST ALL MEDICINES AND DOSES<\/label><textarea id=\"wpforms-4176-field_21\" class=\"wpforms-field-medium\" name=\"wpforms[fields][21]\" ><\/textarea><\/div><div id=\"wpforms-4176-field_62-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-type=\"textarea\" data-field-id=\"62\"><label class=\"wpforms-field-label\" for=\"wpforms-4176-field_62\">New prescription medications that had to be started after the COVID shot(s)<\/label><textarea id=\"wpforms-4176-field_62\" class=\"wpforms-field-medium\" name=\"wpforms[fields][62]\" ><\/textarea><\/div><div id=\"wpforms-4176-field_106-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"106\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><span class=\"wpforms-page-button-group\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"6\" data-formid=\"4176\" disabled>Next<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.truthforhealth.org\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-page-button-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/span><a href=\"#\" class=\"wpforms-save-resume-button\"><span>Save and Continue Later<\/span><\/a><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-7  \" data-page=\"7\" style=\"display:none;\"><div id=\"wpforms-4176-field_22-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"22\"><h3 id=\"wpforms-4176-field_22\">SINCE THE COVID SHOT, have you had any of the following symptoms?<\/h3><\/div><div id=\"wpforms-4176-field_23-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"23\"><label class=\"wpforms-field-label wpforms-label-hide\">Symptoms<\/label><ul id=\"wpforms-4176-field_23\"><li class=\"choice-23 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_23_23\" name=\"wpforms[fields][23][]\" value=\"COVID symptoms or COVID Illness\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_23_23\">COVID symptoms or COVID Illness<\/label><\/li><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_23_1\" name=\"wpforms[fields][23][]\" value=\"Decline in wellbeing\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_23_1\">Decline in wellbeing<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_23_2\" name=\"wpforms[fields][23][]\" value=\"Decline in health status\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_23_2\">Decline in health status<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_23_5\" name=\"wpforms[fields][23][]\" value=\"Extreme fatigue\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_23_5\">Extreme fatigue<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_23_3\" name=\"wpforms[fields][23][]\" value=\"Inability to participate in routine activities\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_23_3\">Inability to participate in routine activities<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_23_4\" name=\"wpforms[fields][23][]\" value=\"Loss of energy\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_23_4\">Loss of energy<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_23_6\" name=\"wpforms[fields][23][]\" value=\"Unexplained pain\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_23_6\">Unexplained pain<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_23_7\" name=\"wpforms[fields][23][]\" value=\"Weakness\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_23_7\">Weakness<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_23_8\" name=\"wpforms[fields][23][]\" value=\"Unexplained fevers\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_23_8\">Unexplained fevers<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_23_10\" name=\"wpforms[fields][23][]\" value=\"Unexplained body sensations\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_23_10\">Unexplained body sensations<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_23_9\" name=\"wpforms[fields][23][]\" value=\"Night sweats\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_23_9\">Night sweats<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_23_11\" name=\"wpforms[fields][23][]\" value=\"Hot flashes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_23_11\">Hot flashes<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_23_12\" name=\"wpforms[fields][23][]\" value=\"Cold intolerance\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_23_12\">Cold intolerance<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_23_13\" name=\"wpforms[fields][23][]\" value=\"Heat intolerance\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_23_13\">Heat intolerance<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_23_14\" name=\"wpforms[fields][23][]\" value=\"Sensitive to temperature changes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_23_14\">Sensitive to temperature changes<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_23_15\" name=\"wpforms[fields][23][]\" value=\"Change in ability to walk\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_23_15\">Change in ability to walk<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_23_16\" name=\"wpforms[fields][23][]\" value=\"Change in thinking\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_23_16\">Change in thinking<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_23_17\" name=\"wpforms[fields][23][]\" value=\"I no longer feel the way I used to\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_23_17\">I no longer feel the way I used to<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_23_18\" name=\"wpforms[fields][23][]\" value=\"Unexplained weight gain\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_23_18\">Unexplained weight gain<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_23_19\" name=\"wpforms[fields][23][]\" value=\"Unexplained weight loss\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_23_19\">Unexplained weight loss<\/label><\/li><li class=\"choice-20 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_23_20\" name=\"wpforms[fields][23][]\" value=\"Fragmented Sleep\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_23_20\">Fragmented Sleep<\/label><\/li><li class=\"choice-21 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_23_21\" name=\"wpforms[fields][23][]\" value=\"Can&#039;t sleep\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_23_21\">Can't sleep<\/label><\/li><li class=\"choice-22 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_23_22\" name=\"wpforms[fields][23][]\" value=\"Insomnia\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_23_22\">Insomnia<\/label><\/li><\/ul><\/div><div id=\"wpforms-4176-field_107-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"107\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><span class=\"wpforms-page-button-group\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"7\" data-formid=\"4176\" disabled>Next<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.truthforhealth.org\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-page-button-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/span><a href=\"#\" class=\"wpforms-save-resume-button\"><span>Save and Continue Later<\/span><\/a><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-8  \" data-page=\"8\" style=\"display:none;\"><div id=\"wpforms-4176-field_25-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"25\"><label class=\"wpforms-field-label\">Head, Eyes, Ears, Nose, Mouth and Throat<\/label><ul id=\"wpforms-4176-field_25\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_1\" name=\"wpforms[fields][25][]\" value=\"Headaches, &quot;fullness&quot; inside head\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_1\">Headaches, \"fullness\" inside head<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_2\" name=\"wpforms[fields][25][]\" value=\"Headaches, migraine\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_2\">Headaches, migraine<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_3\" name=\"wpforms[fields][25][]\" value=\"Headaches, tension\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_3\">Headaches, tension<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_4\" name=\"wpforms[fields][25][]\" value=\"Headaches, throbbing\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_4\">Headaches, throbbing<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_5\" name=\"wpforms[fields][25][]\" value=\"Headaches, other\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_5\">Headaches, other<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_6\" name=\"wpforms[fields][25][]\" value=\"Dry or burning eyes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_6\">Dry or burning eyes<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_7\" name=\"wpforms[fields][25][]\" value=\"Tunnel vision\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_7\">Tunnel vision<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_8\" name=\"wpforms[fields][25][]\" value=\"Blurred vision\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_8\">Blurred vision<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_9\" name=\"wpforms[fields][25][]\" value=\"Loss of vision\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_9\">Loss of vision<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_10\" name=\"wpforms[fields][25][]\" value=\"&quot;Floaters&quot;\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_10\">\"Floaters\"<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_11\" name=\"wpforms[fields][25][]\" value=\"Visual pain\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_11\">Visual pain<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_12\" name=\"wpforms[fields][25][]\" value=\"Conjunctivitis (red eyes)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_12\">Conjunctivitis (red eyes)<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_13\" name=\"wpforms[fields][25][]\" value=\"Discharge from eyes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_13\">Discharge from eyes<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_14\" name=\"wpforms[fields][25][]\" value=\"Loss of taste\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_14\">Loss of taste<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_15\" name=\"wpforms[fields][25][]\" value=\"Loss of smell\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_15\">Loss of smell<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_16\" name=\"wpforms[fields][25][]\" value=\"Sensitive to light\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_16\">Sensitive to light<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_17\" name=\"wpforms[fields][25][]\" value=\"Sensitive to sound\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_17\">Sensitive to sound<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_18\" name=\"wpforms[fields][25][]\" value=\"Sinusitis\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_18\">Sinusitis<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_19\" name=\"wpforms[fields][25][]\" value=\"Sore throat\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_19\">Sore throat<\/label><\/li><li class=\"choice-20 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_20\" name=\"wpforms[fields][25][]\" value=\"Hoarseness\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_20\">Hoarseness<\/label><\/li><li class=\"choice-21 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_21\" name=\"wpforms[fields][25][]\" value=\"Metallic taste\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_21\">Metallic taste<\/label><\/li><li class=\"choice-22 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_22\" name=\"wpforms[fields][25][]\" value=\"White patches on tongue\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_22\">White patches on tongue<\/label><\/li><li class=\"choice-23 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_23\" name=\"wpforms[fields][25][]\" value=\"Tonsillitis\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_23\">Tonsillitis<\/label><\/li><li class=\"choice-24 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_24\" name=\"wpforms[fields][25][]\" value=\"Chronic ear infections\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_24\">Chronic ear infections<\/label><\/li><li class=\"choice-25 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_25\" name=\"wpforms[fields][25][]\" value=\"Ringing in the ears\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_25\">Ringing in the ears<\/label><\/li><li class=\"choice-26 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_26\" name=\"wpforms[fields][25][]\" value=\"Pain in mouth\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_26\">Pain in mouth<\/label><\/li><li class=\"choice-27 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_27\" name=\"wpforms[fields][25][]\" value=\"Sore tongue\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_27\">Sore tongue<\/label><\/li><li class=\"choice-28 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_28\" name=\"wpforms[fields][25][]\" value=\"Ulcers in mouth\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_28\">Ulcers in mouth<\/label><\/li><li class=\"choice-29 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_29\" name=\"wpforms[fields][25][]\" value=\"Blisters in mouth\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_29\">Blisters in mouth<\/label><\/li><li class=\"choice-30 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_30\" name=\"wpforms[fields][25][]\" value=\"Changes to tongue\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_30\">Changes to tongue<\/label><\/li><li class=\"choice-31 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_31\" name=\"wpforms[fields][25][]\" value=\"Ulcers on tongue\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_31\">Ulcers on tongue<\/label><\/li><li class=\"choice-32 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_32\" name=\"wpforms[fields][25][]\" value=\"Blisters on tongue\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_32\">Blisters on tongue<\/label><\/li><li class=\"choice-33 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_33\" name=\"wpforms[fields][25][]\" value=\"Dry mouth\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_33\">Dry mouth<\/label><\/li><li class=\"choice-34 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_34\" name=\"wpforms[fields][25][]\" value=\"Trouble swallowing\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_34\">Trouble swallowing<\/label><\/li><li class=\"choice-35 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_25_35\" name=\"wpforms[fields][25][]\" value=\"&quot;Lump in the throat&quot;\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_25_35\">\"Lump in the throat\"<\/label><\/li><\/ul><\/div><div id=\"wpforms-4176-field_108-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"108\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><span class=\"wpforms-page-button-group\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"8\" data-formid=\"4176\" disabled>Next<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.truthforhealth.org\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-page-button-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/span><a href=\"#\" class=\"wpforms-save-resume-button\"><span>Save and Continue Later<\/span><\/a><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-9  \" data-page=\"9\" style=\"display:none;\"><div id=\"wpforms-4176-field_26-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"26\"><label class=\"wpforms-field-label\">Hematological<\/label><ul id=\"wpforms-4176-field_26\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_26_1\" name=\"wpforms[fields][26][]\" value=\"Low white blood cells\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_26_1\">Low white blood cells<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_26_2\" name=\"wpforms[fields][26][]\" value=\"Low hemoglobin\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_26_2\">Low hemoglobin<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_26_3\" name=\"wpforms[fields][26][]\" value=\"Low hematocrit\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_26_3\">Low hematocrit<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_26_4\" name=\"wpforms[fields][26][]\" value=\"Low red blood cells\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_26_4\">Low red blood cells<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_26_5\" name=\"wpforms[fields][26][]\" value=\"Low platelets\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_26_5\">Low platelets<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_26_6\" name=\"wpforms[fields][26][]\" value=\"High white blood cells\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_26_6\">High white blood cells<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_26_7\" name=\"wpforms[fields][26][]\" value=\"High hemoglobin\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_26_7\">High hemoglobin<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_26_8\" name=\"wpforms[fields][26][]\" value=\"High hematocrit\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_26_8\">High hematocrit<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_26_9\" name=\"wpforms[fields][26][]\" value=\"High D-Dimer\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_26_9\">High D-Dimer<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_26_10\" name=\"wpforms[fields][26][]\" value=\"Elevated Troponin\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_26_10\">Elevated Troponin<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_26_11\" name=\"wpforms[fields][26][]\" value=\"Abnormal cells\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_26_11\">Abnormal cells<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_26_12\" name=\"wpforms[fields][26][]\" value=\"Change in liver function\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_26_12\">Change in liver function<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_26_13\" name=\"wpforms[fields][26][]\" value=\"Change in kidney function\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_26_13\">Change in kidney function<\/label><\/li><\/ul><\/div><div id=\"wpforms-4176-field_27-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"27\"><label class=\"wpforms-field-label\">Respiratory<\/label><ul id=\"wpforms-4176-field_27\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_27_1\" name=\"wpforms[fields][27][]\" value=\"Shortness of breath\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_27_1\">Shortness of breath<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_27_2\" name=\"wpforms[fields][27][]\" value=\"Painful breathing\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_27_2\">Painful breathing<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_27_3\" name=\"wpforms[fields][27][]\" value=\"Difficulty breathing during activity\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_27_3\">Difficulty breathing during activity<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_27_4\" name=\"wpforms[fields][27][]\" value=\"Wheezing\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_27_4\">Wheezing<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_27_5\" name=\"wpforms[fields][27][]\" value=\"Recurrent infections\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_27_5\">Recurrent infections<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_27_6\" name=\"wpforms[fields][27][]\" value=\"Recurrent colds, flu\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_27_6\">Recurrent colds, flu<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_27_7\" name=\"wpforms[fields][27][]\" value=\"Unexplained cough\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_27_7\">Unexplained cough<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_27_8\" name=\"wpforms[fields][27][]\" value=\"Coughing up blood\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_27_8\">Coughing up blood<\/label><\/li><\/ul><\/div><div id=\"wpforms-4176-field_28-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"28\"><label class=\"wpforms-field-label\">Heart and Vascular<\/label><ul id=\"wpforms-4176-field_28\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_28_1\" name=\"wpforms[fields][28][]\" value=\"Chest pain or pressure\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_28_1\">Chest pain or pressure<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_28_2\" name=\"wpforms[fields][28][]\" value=\"Heart palpitations\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_28_2\">Heart palpitations<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_28_3\" name=\"wpforms[fields][28][]\" value=\"Irregular heartbeat\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_28_3\">Irregular heartbeat<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_28_4\" name=\"wpforms[fields][28][]\" value=\"Rapid heart rate\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_28_4\">Rapid heart rate<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_28_5\" name=\"wpforms[fields][28][]\" value=\"Pounding heart\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_28_5\">Pounding heart<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_28_6\" name=\"wpforms[fields][28][]\" value=\"Slow heart rate\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_28_6\">Slow heart rate<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_28_7\" name=\"wpforms[fields][28][]\" value=\"Murmur\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_28_7\">Murmur<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_28_8\" name=\"wpforms[fields][28][]\" value=\"Pain running up left arm\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_28_8\">Pain running up left arm<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_28_9\" name=\"wpforms[fields][28][]\" value=\"Pain in left jaw\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_28_9\">Pain in left jaw<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_28_10\" name=\"wpforms[fields][28][]\" value=\"Low blood pressure\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_28_10\">Low blood pressure<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_28_11\" name=\"wpforms[fields][28][]\" value=\"High blood pressure\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_28_11\">High blood pressure<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_28_12\" name=\"wpforms[fields][28][]\" value=\"High cholesterol\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_28_12\">High cholesterol<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_28_13\" name=\"wpforms[fields][28][]\" value=\"Blood clots\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_28_13\">Blood clots<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_28_14\" name=\"wpforms[fields][28][]\" value=\"Vericose veins\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_28_14\">Vericose veins<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_28_15\" name=\"wpforms[fields][28][]\" value=\"Pain in leg(s)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_28_15\">Pain in leg(s)<\/label><\/li><\/ul><\/div><div id=\"wpforms-4176-field_29-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"29\"><label class=\"wpforms-field-label\">Chest and Breast: Applies to women and men<\/label><ul id=\"wpforms-4176-field_29\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_29_1\" name=\"wpforms[fields][29][]\" value=\"New lumps in breast(s)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_29_1\">New lumps in breast(s)<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_29_2\" name=\"wpforms[fields][29][]\" value=\"Sore, or swollen breasts\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_29_2\">Sore, or swollen breasts<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_29_3\" name=\"wpforms[fields][29][]\" value=\"Discharge from breasts\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_29_3\">Discharge from breasts<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_29_4\" name=\"wpforms[fields][29][]\" value=\"Nipple swelling\/pain\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_29_4\">Nipple swelling\/pain<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_29_5\" name=\"wpforms[fields][29][]\" value=\"Changes to skin of nipples\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_29_5\">Changes to skin of nipples<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_29_6\" name=\"wpforms[fields][29][]\" value=\"Rash on the breast\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_29_6\">Rash on the breast<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_29_7\" name=\"wpforms[fields][29][]\" value=\"Rash on chest\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_29_7\">Rash on chest<\/label><\/li><\/ul><\/div><div id=\"wpforms-4176-field_30-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"30\"><label class=\"wpforms-field-label\">Digestive<\/label><ul id=\"wpforms-4176-field_30\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_30_1\" name=\"wpforms[fields][30][]\" value=\"Unexplained loss of appetite\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_30_1\">Unexplained loss of appetite<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_30_2\" name=\"wpforms[fields][30][]\" value=\"Unusual increase in appetite\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_30_2\">Unusual increase in appetite<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_30_3\" name=\"wpforms[fields][30][]\" value=\"Indigestion\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_30_3\">Indigestion<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_30_4\" name=\"wpforms[fields][30][]\" value=\"Gas\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_30_4\">Gas<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_30_5\" name=\"wpforms[fields][30][]\" value=\"Nausea\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_30_5\">Nausea<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_30_6\" name=\"wpforms[fields][30][]\" value=\"Diarrhea\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_30_6\">Diarrhea<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_30_7\" name=\"wpforms[fields][30][]\" value=\"Constipation\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_30_7\">Constipation<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_30_8\" name=\"wpforms[fields][30][]\" value=\"Vomiting\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_30_8\">Vomiting<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_30_9\" name=\"wpforms[fields][30][]\" value=\"Vomiting blood\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_30_9\">Vomiting blood<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_30_10\" name=\"wpforms[fields][30][]\" value=\"Abdominal pain\/cramping\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_30_10\">Abdominal pain\/cramping<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_30_11\" name=\"wpforms[fields][30][]\" value=\"Rectal pain\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_30_11\">Rectal pain<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_30_12\" name=\"wpforms[fields][30][]\" value=\"Blood in stool\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_30_12\">Blood in stool<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_30_13\" name=\"wpforms[fields][30][]\" value=\"Hemorrhoids\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_30_13\">Hemorrhoids<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_30_14\" name=\"wpforms[fields][30][]\" value=\"Jaundice\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_30_14\">Jaundice<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_30_15\" name=\"wpforms[fields][30][]\" value=\"Brittle and ridged nails\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_30_15\">Brittle and ridged nails<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_30_16\" name=\"wpforms[fields][30][]\" value=\"Bleeding gums\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_30_16\">Bleeding gums<\/label><\/li><\/ul><\/div><div id=\"wpforms-4176-field_31-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"31\"><label class=\"wpforms-field-label\">Endocrine<\/label><ul id=\"wpforms-4176-field_31\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_31_1\" name=\"wpforms[fields][31][]\" value=\"Low blood sugar\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_31_1\">Low blood sugar<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_31_2\" name=\"wpforms[fields][31][]\" value=\"High blood sugar\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_31_2\">High blood sugar<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_31_3\" name=\"wpforms[fields][31][]\" value=\"Thinning scalp hair\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_31_3\">Thinning scalp hair<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_31_4\" name=\"wpforms[fields][31][]\" value=\"Loss of body hair\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_31_4\">Loss of body hair<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_31_5\" name=\"wpforms[fields][31][]\" value=\"Excess body hair\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_31_5\">Excess body hair<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_31_6\" name=\"wpforms[fields][31][]\" value=\"Decreased sweating\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_31_6\">Decreased sweating<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_31_7\" name=\"wpforms[fields][31][]\" value=\"Increased sweating\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_31_7\">Increased sweating<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_31_8\" name=\"wpforms[fields][31][]\" value=\"Slow metabolism\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_31_8\">Slow metabolism<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_31_9\" name=\"wpforms[fields][31][]\" value=\"Abnormal weight gain\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_31_9\">Abnormal weight gain<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_31_10\" name=\"wpforms[fields][31][]\" value=\"Unexplained weight loss\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_31_10\">Unexplained weight loss<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_31_11\" name=\"wpforms[fields][31][]\" value=\"Heat intolerance\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_31_11\">Heat intolerance<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_31_12\" name=\"wpforms[fields][31][]\" value=\"Cold intolerance\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_31_12\">Cold intolerance<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_31_13\" name=\"wpforms[fields][31][]\" value=\"Hot flashes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_31_13\">Hot flashes<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_31_14\" name=\"wpforms[fields][31][]\" value=\"Night sweats\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_31_14\">Night sweats<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_31_15\" name=\"wpforms[fields][31][]\" value=\"Skin discoloration\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_31_15\">Skin discoloration<\/label><\/li><\/ul><\/div><div id=\"wpforms-4176-field_109-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"109\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><span class=\"wpforms-page-button-group\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"9\" data-formid=\"4176\" disabled>Next<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.truthforhealth.org\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-page-button-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/span><a href=\"#\" class=\"wpforms-save-resume-button\"><span>Save and Continue Later<\/span><\/a><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-10  \" data-page=\"10\" style=\"display:none;\"><div id=\"wpforms-4176-field_32-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"32\"><label class=\"wpforms-field-label\">Reproductive and Bladder<\/label><ul id=\"wpforms-4176-field_32\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_32_1\" name=\"wpforms[fields][32][]\" value=\"Bladder infections\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_32_1\">Bladder infections<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_32_2\" name=\"wpforms[fields][32][]\" value=\"Frequent urination\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_32_2\">Frequent urination<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_32_3\" name=\"wpforms[fields][32][]\" value=\"Urinary leakage\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_32_3\">Urinary leakage<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_32_4\" name=\"wpforms[fields][32][]\" value=\"Urgency to urinate\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_32_4\">Urgency to urinate<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_32_5\" name=\"wpforms[fields][32][]\" value=\"Pain on urination\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_32_5\">Pain on urination<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_32_6\" name=\"wpforms[fields][32][]\" value=\"Blood in urine\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_32_6\">Blood in urine<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_32_7\" name=\"wpforms[fields][32][]\" value=\"Clots in urine\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_32_7\">Clots in urine<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_32_8\" name=\"wpforms[fields][32][]\" value=\"Difficulty urinating\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_32_8\">Difficulty urinating<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_32_9\" name=\"wpforms[fields][32][]\" value=\"Recurrent bladder infections\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_32_9\">Recurrent bladder infections<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_32_10\" name=\"wpforms[fields][32][]\" value=\"Recurrent yeast infections\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_32_10\">Recurrent yeast infections<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_32_11\" name=\"wpforms[fields][32][]\" value=\"Incontinence\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_32_11\">Incontinence<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_32_12\" name=\"wpforms[fields][32][]\" value=\"Mass in bladder\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_32_12\">Mass in bladder<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_32_13\" name=\"wpforms[fields][32][]\" value=\"Blood clots in bladder\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_32_13\">Blood clots in bladder<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_32_14\" name=\"wpforms[fields][32][]\" value=\"Dryness of vagina\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_32_14\">Dryness of vagina<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_32_15\" name=\"wpforms[fields][32][]\" value=\"Periods have stopped\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_32_15\">Periods have stopped<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_32_16\" name=\"wpforms[fields][32][]\" value=\"Irregular periods\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_32_16\">Irregular periods<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_32_17\" name=\"wpforms[fields][32][]\" value=\"Light periods\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_32_17\">Light periods<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_32_18\" name=\"wpforms[fields][32][]\" value=\"Heavy periods\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_32_18\">Heavy periods<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_32_19\" name=\"wpforms[fields][32][]\" value=\"Clotting with periods\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_32_19\">Clotting with periods<\/label><\/li><li class=\"choice-20 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_32_20\" name=\"wpforms[fields][32][]\" value=\"Excessively painful periods\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_32_20\">Excessively painful periods<\/label><\/li><li class=\"choice-25 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_32_25\" name=\"wpforms[fields][32][]\" value=\"Prolonged postpartum bleeding\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_32_25\">Prolonged postpartum bleeding<\/label><\/li><li class=\"choice-21 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_32_21\" name=\"wpforms[fields][32][]\" value=\"Erectile dysfunction \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_32_21\">Erectile dysfunction<\/label><\/li><li class=\"choice-22 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_32_22\" name=\"wpforms[fields][32][]\" value=\"Penile pain\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_32_22\">Penile pain<\/label><\/li><li class=\"choice-23 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_32_23\" name=\"wpforms[fields][32][]\" value=\"Fertility changes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_32_23\">Fertility changes<\/label><\/li><li class=\"choice-24 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_32_24\" name=\"wpforms[fields][32][]\" value=\"Miscarriages\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_32_24\">Miscarriages<\/label><\/li><\/ul><\/div><div id=\"wpforms-4176-field_110-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"110\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><span class=\"wpforms-page-button-group\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"10\" data-formid=\"4176\" disabled>Next<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.truthforhealth.org\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-page-button-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/span><a href=\"#\" class=\"wpforms-save-resume-button\"><span>Save and Continue Later<\/span><\/a><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-11  \" data-page=\"11\" style=\"display:none;\"><div id=\"wpforms-4176-field_33-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"33\"><label class=\"wpforms-field-label\">Musculoskeletal<\/label><ul id=\"wpforms-4176-field_33\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_33_1\" name=\"wpforms[fields][33][]\" value=\"Joint pain\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_33_1\">Joint pain<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_33_2\" name=\"wpforms[fields][33][]\" value=\"Backache\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_33_2\">Backache<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_33_3\" name=\"wpforms[fields][33][]\" value=\"Neck pain\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_33_3\">Neck pain<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_33_4\" name=\"wpforms[fields][33][]\" value=\"Loss of height\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_33_4\">Loss of height<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_33_5\" name=\"wpforms[fields][33][]\" value=\"Numbness and tingling\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_33_5\">Numbness and tingling<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_33_6\" name=\"wpforms[fields][33][]\" value=\"Restless legs in sleep\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_33_6\">Restless legs in sleep<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_33_7\" name=\"wpforms[fields][33][]\" value=\"Leg pain\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_33_7\">Leg pain<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_33_8\" name=\"wpforms[fields][33][]\" value=\"Hip pain\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_33_8\">Hip pain<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_33_9\" name=\"wpforms[fields][33][]\" value=\"Bone pain\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_33_9\">Bone pain<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_33_10\" name=\"wpforms[fields][33][]\" value=\"Sore muscles\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_33_10\">Sore muscles<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_33_11\" name=\"wpforms[fields][33][]\" value=\"Reduced range of motion\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_33_11\">Reduced range of motion<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_33_12\" name=\"wpforms[fields][33][]\" value=\"Stiff joints\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_33_12\">Stiff joints<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_33_13\" name=\"wpforms[fields][33][]\" value=\"Difficulty walking\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_33_13\">Difficulty walking<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_33_14\" name=\"wpforms[fields][33][]\" value=\"Muscle spasms\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_33_14\">Muscle spasms<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_33_17\" name=\"wpforms[fields][33][]\" value=\"Muscle twitches\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_33_17\">Muscle twitches<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_33_16\" name=\"wpforms[fields][33][]\" value=\"Muscle weakness\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_33_16\">Muscle weakness<\/label><\/li><\/ul><\/div><div id=\"wpforms-4176-field_34-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"34\"><label class=\"wpforms-field-label\">Skin<\/label><ul id=\"wpforms-4176-field_34\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_34_1\" name=\"wpforms[fields][34][]\" value=\"Acne\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_34_1\">Acne<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_34_2\" name=\"wpforms[fields][34][]\" value=\"Boils, blisters\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_34_2\">Boils, blisters<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_34_3\" name=\"wpforms[fields][34][]\" value=\"Bruising\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_34_3\">Bruising<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_34_4\" name=\"wpforms[fields][34][]\" value=\"Cysts\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_34_4\">Cysts<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_34_5\" name=\"wpforms[fields][34][]\" value=\"Dry\/scaly skin\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_34_5\">Dry\/scaly skin<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_34_6\" name=\"wpforms[fields][34][]\" value=\"Eczema\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_34_6\">Eczema<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_34_7\" name=\"wpforms[fields][34][]\" value=\"Hives\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_34_7\">Hives<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_34_8\" name=\"wpforms[fields][34][]\" value=\"Itching, crawling skin\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_34_8\">Itching, crawling skin<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_34_9\" name=\"wpforms[fields][34][]\" value=\"Mole(s) changes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_34_9\">Mole(s) changes<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_34_10\" name=\"wpforms[fields][34][]\" value=\"Pigment changes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_34_10\">Pigment changes<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_34_11\" name=\"wpforms[fields][34][]\" value=\"Rashes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_34_11\">Rashes<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_34_12\" name=\"wpforms[fields][34][]\" value=\"Wounds not healing\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_34_12\">Wounds not healing<\/label><\/li><\/ul><\/div><div id=\"wpforms-4176-field_111-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"111\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><span class=\"wpforms-page-button-group\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"11\" data-formid=\"4176\" disabled>Next<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.truthforhealth.org\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-page-button-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/span><a href=\"#\" class=\"wpforms-save-resume-button\"><span>Save and Continue Later<\/span><\/a><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-12  \" data-page=\"12\" style=\"display:none;\"><div id=\"wpforms-4176-field_35-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"35\"><label class=\"wpforms-field-label\">Neurological<\/label><ul id=\"wpforms-4176-field_35\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_35_1\" name=\"wpforms[fields][35][]\" value=\"New onset seizures\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_35_1\">New onset seizures<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_35_2\" name=\"wpforms[fields][35][]\" value=\"Trembling\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_35_2\">Trembling<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_35_3\" name=\"wpforms[fields][35][]\" value=\"Twitching\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_35_3\">Twitching<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_35_4\" name=\"wpforms[fields][35][]\" value=\"Numbness\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_35_4\">Numbness<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_35_5\" name=\"wpforms[fields][35][]\" value=\"Tingling\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_35_5\">Tingling<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_35_6\" name=\"wpforms[fields][35][]\" value=\"Burning sensations\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_35_6\">Burning sensations<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_35_7\" name=\"wpforms[fields][35][]\" value=\"Electric shock sensations\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_35_7\">Electric shock sensations<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_35_8\" name=\"wpforms[fields][35][]\" value=\"&quot;Pins and needles&quot; sensation\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_35_8\">\"Pins and needles\" sensation<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_35_9\" name=\"wpforms[fields][35][]\" value=\"Crawling sensation\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_35_9\">Crawling sensation<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_35_10\" name=\"wpforms[fields][35][]\" value=\"Involuntary muscle contractions\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_35_10\">Involuntary muscle contractions<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_35_11\" name=\"wpforms[fields][35][]\" value=\"Unexplained pain\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_35_11\">Unexplained pain<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_35_12\" name=\"wpforms[fields][35][]\" value=\"Loss of strength\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_35_12\">Loss of strength<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_35_13\" name=\"wpforms[fields][35][]\" value=\"Difficulty moving body\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_35_13\">Difficulty moving body<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_35_14\" name=\"wpforms[fields][35][]\" value=\"Clumsiness\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_35_14\">Clumsiness<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_35_15\" name=\"wpforms[fields][35][]\" value=\"Change in balance\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_35_15\">Change in balance<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_35_16\" name=\"wpforms[fields][35][]\" value=\"Loss of coordination\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_35_16\">Loss of coordination<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_35_17\" name=\"wpforms[fields][35][]\" value=\"Dizziness\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_35_17\">Dizziness<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_35_18\" name=\"wpforms[fields][35][]\" value=\"Vertigo\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_35_18\">Vertigo<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_35_19\" name=\"wpforms[fields][35][]\" value=\"Fainting spells\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_35_19\">Fainting spells<\/label><\/li><li class=\"choice-20 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_35_20\" name=\"wpforms[fields][35][]\" value=\"Brain &quot;Fog&quot;\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_35_20\">Brain \"Fog\"<\/label><\/li><li class=\"choice-21 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_35_21\" name=\"wpforms[fields][35][]\" value=\"Difficulty concentrating\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_35_21\">Difficulty concentrating<\/label><\/li><li class=\"choice-22 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_35_22\" name=\"wpforms[fields][35][]\" value=\"Confusion\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_35_22\">Confusion<\/label><\/li><li class=\"choice-23 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_35_23\" name=\"wpforms[fields][35][]\" value=\"Forgetfulness\/Memory loss\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_35_23\">Forgetfulness\/Memory loss<\/label><\/li><li class=\"choice-24 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_35_24\" name=\"wpforms[fields][35][]\" value=\"Slowed speech\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_35_24\">Slowed speech<\/label><\/li><li class=\"choice-25 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_35_25\" name=\"wpforms[fields][35][]\" value=\"Insomnia\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_35_25\">Insomnia<\/label><\/li><li class=\"choice-26 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_35_26\" name=\"wpforms[fields][35][]\" value=\"Restless, fragmented sleep\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_35_26\">Restless, fragmented sleep<\/label><\/li><li class=\"choice-27 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_35_27\" name=\"wpforms[fields][35][]\" value=\"Sleepiness (daytime)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_35_27\">Sleepiness (daytime)<\/label><\/li><li class=\"choice-28 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_35_28\" name=\"wpforms[fields][35][]\" value=\"Brain lesions\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_35_28\">Brain lesions<\/label><\/li><\/ul><\/div><div id=\"wpforms-4176-field_112-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-type=\"pagebreak\" data-field-id=\"112\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><span class=\"wpforms-page-button-group\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"12\" data-formid=\"4176\" disabled>Next<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.truthforhealth.org\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-page-button-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/span><a href=\"#\" class=\"wpforms-save-resume-button\"><span>Save and Continue Later<\/span><\/a><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-13  \" data-page=\"13\" style=\"display:none;\"><div id=\"wpforms-4176-field_36-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"36\"><label class=\"wpforms-field-label\">Psychological Changes<\/label><ul id=\"wpforms-4176-field_36\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-4176-field_36_1\" name=\"wpforms[fields][36][]\" value=\"Aggression\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-4176-field_36_1\">Aggression<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" 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