{"id":41,"date":"2025-02-09T17:08:23","date_gmt":"2025-02-09T17:08:23","guid":{"rendered":"https:\/\/www.embryowish.com\/?page_id=41"},"modified":"2025-05-28T07:39:31","modified_gmt":"2025-05-28T07:39:31","slug":"ivf-questionnaire","status":"publish","type":"page","link":"https:\/\/www.embryowish.com\/en\/ivf-questionnaire\/","title":{"rendered":"QUESTIONNAIRE"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row el_class=&#8221;.pageTopCover&#8221;][vc_column][vc_row_inner][vc_column_inner][vc_wp_text]<img loading=\"lazy\" decoding=\"async\" class=\"alignnone\" src=\"https:\/\/www.embryowish.com\/wp-content\/uploads\/2025\/04\/cover_questionnaire.png\" alt=\"ivf questionnaire\" width=\"1100\" height=\"750\" \/>[\/vc_wp_text][\/vc_column_inner][\/vc_row_inner][\/vc_column][\/vc_row][vc_row][vc_column][vc_row_inner el_class=&#8221;.pageTop&#8221;][vc_column_inner][vc_wp_text]<\/p>\n<h1>Questionnaire<\/h1>\n<p>[\/vc_wp_text][\/vc_column_inner][\/vc_row_inner][vc_row_inner][vc_column_inner el_class=&#8221;.pageSubTitle&#8221; width=&#8221;2\/3&#8243;][vc_column_text el_class=&#8221;.pageTopSubtitle&#8221;]It is essential for us to fully understand your medical history in order to provide you with the best possible treatment and support. Proper information is the first step towards finding the best solution for your fertility.[\/vc_column_text][\/vc_column_inner][vc_column_inner width=&#8221;1\/3&#8243;][\/vc_column_inner][\/vc_row_inner][\/vc_column][\/vc_row][vc_row el_class=&#8221;.pageTopPusher&#8221;][vc_column][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text]<div class=\"wpb-content-wrapper\"><p>[vc_row][vc_column width=&#8221;1\/12&#8243;][\/vc_column][vc_column width=&#8221;5\/6&#8243;][vc_row_inner el_class=&#8221;.pageTopBar&#8221;][vc_column_inner width=&#8221;1\/3&#8243;][vc_wp_text]<img decoding=\"async\" class=\"center-block\" src=\"https:\/\/www.embryowish.com\/wp-content\/themes\/embryowish\/assets\/top_bar_01.svg\" width=\"50\" \/>[\/vc_wp_text][vc_column_text]<\/p>\n<p style=\"text-align: center;\"><a href=\"https:\/\/www.embryowish.com\/en\/egg-donors\/\">Egg Donors<\/a><\/p>\n<p>[\/vc_column_text][vc_empty_space el_class=&#8221;.visible-xs .visible-sm&#8221;][\/vc_column_inner][vc_column_inner width=&#8221;1\/3&#8243;][vc_wp_text]<img decoding=\"async\" class=\"center-block\" src=\"https:\/\/www.embryowish.com\/wp-content\/themes\/embryowish\/assets\/top_bar_03.svg\" width=\"45\" \/>[\/vc_wp_text][vc_column_text]<\/p>\n<p style=\"text-align: center;\"><a href=\"https:\/\/www.embryowish.com\/en\/ivf-questionnaire\/\">Questionnaire<\/a><\/p>\n<p>[\/vc_column_text][\/vc_column_inner][vc_column_inner width=&#8221;1\/3&#8243;][vc_wp_text]<img decoding=\"async\" class=\"center-block\" src=\"https:\/\/www.embryowish.com\/wp-content\/themes\/embryowish\/assets\/top_bar_03_01.svg\" width=\"45\" \/>[\/vc_wp_text][vc_column_text]<\/p>\n<p style=\"text-align: center;\"><a href=\"https:\/\/www.embryowish.com\/en\/embryowish-contact\/\">Contact us<\/a><\/p>\n<p>[\/vc_column_text][\/vc_column_inner][\/vc_row_inner][\/vc_column][vc_column width=&#8221;1\/12&#8243;][\/vc_column][\/vc_row][vc_row][vc_column][vc_empty_space][\/vc_column][\/vc_row]<\/p>\n<\/div>[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text]<\/p>\n<p style=\"text-align: center;\">\u00a0Please complete the following questionnaire with all necessary information<br \/>\nso that we can proceed with analyzing and designing the appropriate approach for your case.<\/p>\n<p>[\/vc_column_text][vc_column_text]\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f413-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/41#wpcf7-f413-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"413\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.7.7\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f413-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<div class=\"row\">\n\t<div class=\"col-md-12 nopadding\">\n\t\t<div class=\"col-md-12\">\n\t\t\t<h3>Female Information\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div class=\"col-md-6 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Name\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-6 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-surname\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Surname\" value=\"\" type=\"text\" name=\"your-surname\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-6 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-dateofbirth\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Date of Birth (mm\/dd\/yyyy)\" value=\"\" type=\"text\" name=\"your-dateofbirth\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-6 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Address\" value=\"\" type=\"text\" name=\"your-address\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"col-md-12 nopadding\">\n\t\t<div class=\"col-md-6 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-country\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Country\" value=\"\" type=\"text\" name=\"your-country\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-6 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-phone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Phone\" value=\"\" type=\"text\" name=\"your-phone\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-6 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Email\" value=\"\" type=\"text\" name=\"your-email\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-6 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-emailverify\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Email Verify\" value=\"\" type=\"text\" name=\"your-emailverify\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-6 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-profession\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Profession\" value=\"\" type=\"text\" name=\"your-profession\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-6 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-marital-status\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Marital Status\" value=\"\" type=\"text\" name=\"your-marital-status\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"col-md-12 nopadding\">\n\t\t<div class=\"col-md-12 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-period\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Period (when it comes, how many days it lasts)\" name=\"your-period\"><\/textarea><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-12 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-hormone-results\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Results of last hormone profile (LH, FSH, E2, TSH, PRL)\" name=\"your-hormone-results\"><\/textarea><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-12 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-pap-results\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Latest Pap test results\" name=\"your-pap-results\"><\/textarea><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-12 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-history-medications\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"History of taking medications\" name=\"your-history-medications\"><\/textarea><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-12 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-previous-surgeries\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Previous surgeries\" name=\"your-previous-surgeries\"><\/textarea><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-12 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-immune-problems\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Immune or autoimmune problems\" name=\"your-immune-problems\"><\/textarea><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-12 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-thrombophilia\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Thrombophilia check\" name=\"your-thrombophilia\"><\/textarea><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-12 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-screening-infection\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Screening for mycoplasma, ureaplasma, chlamydia, or any other infection\" name=\"your-screening-infection\"><\/textarea><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"col-md-12 nopadding\">\n\t\t<div class=\"col-md-6 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-Hysterosalpingography\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Hysterosalpingography\" value=\"\" type=\"text\" name=\"your-Hysterosalpingography\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-6 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-karyotype\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Check for karyotype\" value=\"\" type=\"text\" name=\"your-karyotype\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"col-md-12 nopadding\">\n\t\t<div class=\"col-md-12 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-health-problems\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Health problems, such as allergies or chronic conditions and surgeries\" name=\"your-health-problems\"><\/textarea><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-12 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-other-findings\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Other findings about your fertility\" name=\"your-other-findings\"><\/textarea><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-12 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-previous-ivf\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Previous IVF attempts (results, etc.)\" name=\"your-previous-ivf\"><\/textarea><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"col-md-12 nopadding\">\n\t\t<div class=\"col-md-6 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-weight\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Weight\" value=\"\" type=\"text\" name=\"your-weight\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-6 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-height\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Height\" value=\"\" type=\"text\" name=\"your-height\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"col-md-12 nopadding\">\n\t\t<div class=\"col-md-12\">\n\t\t\t<h3>Male Information\n\t\t\t<\/h3>\n\t\t<\/div>\n\t\t<div class=\"col-md-6 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-name-male\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Name\" value=\"\" type=\"text\" name=\"your-name-male\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-6 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-surname-male\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Surname\" value=\"\" type=\"text\" name=\"your-surname-male\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-6 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-dateofbirth-male\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Date of Birth (mm\/dd\/yyyy)\" value=\"\" type=\"text\" name=\"your-dateofbirth-male\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-6 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-address-male\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Address\" value=\"\" type=\"text\" name=\"your-address-male\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"col-md-12 nopadding\">\n\t\t<div class=\"col-md-6 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-phone-male\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Phone\" value=\"\" type=\"text\" name=\"your-phone-male\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-6 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-profession-male\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Profession\" value=\"\" type=\"text\" name=\"your-profession-male\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-6 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-marital-status-male\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Marital Status\" value=\"\" type=\"text\" name=\"your-marital-status-male\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-6 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-karyotype-male\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Check for karyotype\" value=\"\" type=\"text\" name=\"your-karyotype-male\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"col-md-12 nopadding\">\n\t\t<div class=\"col-md-12 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-recent-sperm-male\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Recent sperm analysis results\" name=\"your-recent-sperm-male\"><\/textarea><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-12 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-previous-surgeries-male\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Previous surgeries\" name=\"your-previous-surgeries-male\"><\/textarea><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-12 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-chronic-diseasses-male\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Chronic diseases\" name=\"your-chronic-diseasses-male\"><\/textarea><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-12 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-medication-history-male\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Medication history\" name=\"your-medication-history-male\"><\/textarea><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"col-md-12 nopadding\">\n\t\t<div class=\"col-md-6 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-weight-male\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Weight\" value=\"\" type=\"text\" name=\"your-weight-male\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"col-md-6 spacer\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-height-male\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" 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