{"id":1793,"date":"2017-07-31T01:48:38","date_gmt":"2017-07-31T01:48:38","guid":{"rendered":"https:\/\/dev.metronorth.health.qld.gov.au\/caboolture\/?post_type=services&#038;p=1793"},"modified":"2023-11-16T08:52:45","modified_gmt":"2023-11-15T22:52:45","slug":"caboolture-hospital-antenatal-clinical-triage-form","status":"publish","type":"services","link":"https:\/\/metronorth.health.qld.gov.au\/caboolture\/healthcare-services\/maternity-services\/caboolture-hospital-antenatal-clinical-triage-form","title":{"rendered":"Antenatal Clinical Triage Form"},"content":{"rendered":"","protected":false},"excerpt":{"rendered":"<p>Caboolture Hospital Antenatal Clinical Triage Form<\/p>\n","protected":false},"featured_media":0,"parent":654,"menu_order":0,"template":"","categories":[1],"tags":[184,223,344,1151,1152],"class_list":["post-1793","services","type-services","status-publish","hentry","category-uncategorized","tag-appointment","tag-pregnancy","tag-maternity","tag-antenatal-clinical-triage-form","tag-online-registration"],"acf":{"page_subtitle":"","page_type":"general","page_sections_general":[],"accessing_this_service":[{"variation":"GP or medical practitioner referral","free_text":""}],"include_refer_a_patient_panel":true,"refer_a_patient_text":"","refer_a_patient_link":"","specialist_hotline":"1300 364 938","after_your_hospital_appointment":[{"variation":"Preadmission and surgery","free_text":""}],"general_content_0":false,"what_to_bring":[{"category":"general","what_to_bring_general":[{"display":[],"every_time":"","_copy":"","for_appointment":"","_copy2":"","for_procedure":"","_copy3":""}],"what_to_bring_mental_health":false,"what_to_bring_child_health":false}],"general_content":[{"other_content":[{"heading":"","content":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last\" style=\"--awb-padding-top:20px;--awb-padding-right:20px;--awb-padding-bottom:20px;--awb-padding-left:20px;--awb-bg-color:#f1f1f1;--awb-bg-color-hover:#f1f1f1;--awb-bg-size:cover;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\"><div class=\"fusion-text fusion-text-1\"><h3 data-fontsize=\"21\" data-lineheight=\"26\">Collection notice<\/h3>\n<p>Queensland Health (QH) is required to manage your personal information in accordance with the Information Privacy Act 2009 and the Hospital and Health Boards Act 2011, Part 7 Confidentiality. QH is collecting the personal information on this form to assist in chart preparation for your pregnancy booking in visit and to assess your individual pregnancy health care needs. This form will be printed and filed in your patient medical record. Some of your personal information on your medical record may be given to carers, guardians or other government departments who provide associated services that require your information for the purpose of providing a health care service. Your information will be disclosed without your consent, if authorised or required by law. For further information about privacy and your health record please ask for a copy of the Queensland Health Privacy Brochure or visit <a href=\"http:\/\/www.health.qld.gov.au\/\">www.health.qld.gov.au<\/a>. <\/p>\n<\/div><div class=\"fusion-text fusion-text-2\"><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]&gt; *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_1' style='display:none'><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/caboolture\/wp-json\/wp\/v2\/healthcare-services\/1793#gf_1' data-formid='1' novalidate>\n        <div id='gf_progressbar_wrapper_1' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<h3 class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>6<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_16' style='width:16%;'><span>16%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_1_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_3\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Required fields are marked with an asterisk (<span class=\"gfield_required\" style=\"margin-left:0\">*<\/span>)<\/p><\/li><li id=\"field_1_66\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Personal details<\/h3><\/li><li id=\"field_1_4\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name has_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_1_4'>\n                            <span id='input_1_4_2_container' class='name_prefix name_prefix_select gform-grid-col gform-grid-col--size-auto' >\n                                                    <select name='input_4.2' id='input_1_4_2'    aria-required='false'   >\n                          <option value=''>Title<\/option><option value='Ms.' >Ms.<\/option><option value='Miss' >Miss<\/option><option value='Mrs.' >Mrs.<\/option><option value='Mr.' >Mr.<\/option><option value='Dr.' >Dr.<\/option><option value='Prof.' >Prof.<\/option><option value='Rev.' >Rev.<\/option>\n                      <\/select>\n                                                    <label for='input_1_4_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Prefix<\/label>\n                                                  <\/span>\n                            <span id='input_1_4_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_4.3' id='input_1_4_3' value=''   aria-required='true'   placeholder='First name'  \/>\n                                                    <label for='input_1_4_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_4_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_4.6' id='input_1_4_6' value=''   aria-required='true'   placeholder='Last name'  \/>\n                                                    <label for='input_1_4_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_6\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_6'>Previous family name (if applicable)<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_1_6' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_7\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_1_7' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\">\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_1_7_2_container'>\n                                            <input type='number' maxlength='2' name='input_7[]' id='input_1_7_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_1_7_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_7_1_container'>\n                                        <input type='number' maxlength='2' name='input_7[]' id='input_1_7_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                        <label for='input_1_7_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_1_7_3_container'>\n                                        <input type='number' maxlength='4' name='input_7[]' id='input_1_7_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                        <label for='input_1_7_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label>\n                                   <\/div>\n                                <\/div><\/div><\/li><li id=\"field_1_67\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_67'>Age<\/label><div class='ginput_container ginput_container_number'><input name='input_67' id='input_1_67' type='text' step='any'   value='' class='small'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_12\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_12'>Country of birth<\/label><div class='ginput_container ginput_container_select'><select name='input_12' id='input_1_12' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select<\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brazil' >Brazil<\/option><option value='Brunei' >Brunei<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='East Timor' >East Timor<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='North Korea' >North Korea<\/option><option value='South Korea' >South Korea<\/option><option value='Kosovo' >Kosovo<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Laos' >Laos<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Sudan, South' >Sudan, South<\/option><option value='Suriname' >Suriname<\/option><option value='Swaziland' >Swaziland<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Togo' >Togo<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Vatican City' >Vatican City<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><\/select><\/div><\/li><li id=\"field_1_13\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_13'>Marital status<\/label><div class='ginput_container ginput_container_select'><select name='input_13' id='input_1_13' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select<\/option><option value='Married \/ De facto' >Married \/ De facto<\/option><option value='Never married' >Never married<\/option><option value='Widowed' >Widowed<\/option><option value='Seperated' >Seperated<\/option><option value='Divorced' >Divorced<\/option><\/select><\/div><\/li><li id=\"field_1_14\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_14'>What language do you speak at home?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_1_14' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you require an interpreter?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_15'>\n\t\t\t<li class='gchoice gchoice_1_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='Yes'  id='choice_1_15_0'    \/>\n\t\t\t\t<label for='choice_1_15_0' id='label_1_15_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='No'  id='choice_1_15_1'    \/>\n\t\t\t\t<label for='choice_1_15_1' id='label_1_15_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_16\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_16'>For which language?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_16'>For which language do you require an interpreter?<\/div><div class='ginput_container ginput_container_text'><input name='input_16' id='input_1_16' type='text' value='' class='small'  aria-describedby=\"gfield_description_1_16\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_17\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_17'>Religion<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_1_17' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_18\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you have a current Health Directive in place?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_18'>\n\t\t\t<li class='gchoice gchoice_1_18_0'>\n\t\t\t\t<input name='input_18' type='radio' value='Yes - please bring a copy with you at your first appointment'  id='choice_1_18_0'    \/>\n\t\t\t\t<label for='choice_1_18_0' id='label_1_18_0' class='gform-field-label gform-field-label--type-inline'>Yes - please bring a copy with you at your first appointment<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_18_1'>\n\t\t\t\t<input name='input_18' type='radio' value='No'  id='choice_1_18_1'    \/>\n\t\t\t\t<label for='choice_1_18_1' id='label_1_18_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_19\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you of Aboriginal and\/or Torres Strait Islander origin?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_19'>\n\t\t\t<li class='gchoice gchoice_1_19_0'>\n\t\t\t\t<input name='input_19' type='radio' value='No'  id='choice_1_19_0'    \/>\n\t\t\t\t<label for='choice_1_19_0' id='label_1_19_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_19_1'>\n\t\t\t\t<input name='input_19' type='radio' value='Yes, Aboriginal'  id='choice_1_19_1'    \/>\n\t\t\t\t<label for='choice_1_19_1' id='label_1_19_1' class='gform-field-label gform-field-label--type-inline'>Yes, Aboriginal<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_19_2'>\n\t\t\t\t<input name='input_19' type='radio' value='Yes, Torres Strait Islander'  id='choice_1_19_2'    \/>\n\t\t\t\t<label for='choice_1_19_2' id='label_1_19_2' class='gform-field-label gform-field-label--type-inline'>Yes, Torres Strait Islander<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_19_3'>\n\t\t\t\t<input name='input_19' type='radio' value='Yes, both Aboriginal and Torres Strait Islander'  id='choice_1_19_3'    \/>\n\t\t\t\t<label for='choice_1_19_3' id='label_1_19_3' class='gform-field-label gform-field-label--type-inline'>Yes, both Aboriginal and Torres Strait Islander<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Does the father of your baby identify as an Aboriginal or Torres Strait Islander?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_20'>\n\t\t\t<li class='gchoice gchoice_1_20_0'>\n\t\t\t\t<input name='input_20' type='radio' value='No'  id='choice_1_20_0'    \/>\n\t\t\t\t<label for='choice_1_20_0' id='label_1_20_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_20_1'>\n\t\t\t\t<input name='input_20' type='radio' value='Yes'  id='choice_1_20_1'    \/>\n\t\t\t\t<label for='choice_1_20_1' id='label_1_20_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_21\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Contact details<\/h3><\/li><li id=\"field_1_22\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Your home address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_zip ginput_container_address gform-grid-row' id='input_1_22' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_22_1_container' >\n                                        <input type='text' name='input_22.1' id='input_1_22_1' value=''   placeholder='Street address' aria-required='true'    \/>\n                                        <label for='input_1_22_1' id='input_1_22_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_22_2_container' >\n                                        <input type='text' name='input_22.2' id='input_1_22_2' value=''   placeholder='Address line 2'  aria-required='false'   \/>\n                                        <label for='input_1_22_2' id='input_1_22_2_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_22_3_container' >\n                                    <input type='text' name='input_22.3' id='input_1_22_3' value=''   placeholder='Suburb' aria-required='true'    \/>\n                                    <label for='input_1_22_3' id='input_1_22_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Suburb<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_22.4' id='input_1_22_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_1_22_5_container' >\n                                    <input type='text' name='input_22.5' id='input_1_22_5' value=''   placeholder='Postcode' aria-required='true'    \/>\n                                    <label for='input_1_22_5' id='input_1_22_5_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Postcode<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_22.6' id='input_1_22_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_23\" class=\"gfield gfield--type-address field_sublabel_hidden_label gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Postal address<\/label><div class='gfield_description' id='gfield_description_1_23'>If different to home address<\/div>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_zip ginput_container_address gform-grid-row' id='input_1_23' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_23_1_container' >\n                                        <input type='text' name='input_23.1' id='input_1_23_1' value=''   placeholder='Street address' aria-required='false'    \/>\n                                        <label for='input_1_23_1' id='input_1_23_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_23_2_container' >\n                                        <input type='text' name='input_23.2' id='input_1_23_2' value=''   placeholder='Address line 2'  aria-required='false'   \/>\n                                        <label for='input_1_23_2' id='input_1_23_2_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_23_3_container' >\n                                    <input type='text' name='input_23.3' id='input_1_23_3' value=''   placeholder='Suburb' aria-required='false'    \/>\n                                    <label for='input_1_23_3' id='input_1_23_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Suburb<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_23.4' id='input_1_23_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_1_23_5_container' >\n                                    <input type='text' name='input_23.5' id='input_1_23_5' value=''   placeholder='Postcode' aria-required='false'    \/>\n                                    <label for='input_1_23_5' id='input_1_23_5_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Postcode<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_23.6' id='input_1_23_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_24\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_24'>Contact number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_24' id='input_1_24' type='tel' value='' class='small'  placeholder='Home or mobile' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_25\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_25'>Contact number<\/label><div class='ginput_container ginput_container_phone'><input name='input_25' id='input_1_25' type='tel' value='' class='small'  placeholder='Home or mobile'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_26\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_26'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_26' id='input_1_26' type='email' value='' class='small'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_1_196\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you happy to receive notification via text message or email?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_196'>\n\t\t\t<li class='gchoice gchoice_1_196_0'>\n\t\t\t\t<input name='input_196' type='radio' value='Text message (SMS)'  id='choice_1_196_0'    \/>\n\t\t\t\t<label for='choice_1_196_0' id='label_1_196_0' class='gform-field-label gform-field-label--type-inline'>Text message (SMS)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_196_1'>\n\t\t\t\t<input name='input_196' type='radio' value='Email'  id='choice_1_196_1'    \/>\n\t\t\t\t<label for='choice_1_196_1' id='label_1_196_1' class='gform-field-label gform-field-label--type-inline'>Email<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_196_2'>\n\t\t\t\t<input name='input_196' type='radio' value='Both text message and email'  id='choice_1_196_2'    \/>\n\t\t\t\t<label for='choice_1_196_2' id='label_1_196_2' class='gform-field-label gform-field-label--type-inline'>Both text message and email<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_196_3'>\n\t\t\t\t<input name='input_196' type='radio' value='Neither, please call me'  id='choice_1_196_3'    \/>\n\t\t\t\t<label for='choice_1_196_3' id='label_1_196_3' class='gform-field-label gform-field-label--type-inline'>Neither, please call me<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_27\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Next of kin<\/h3><\/li><li id=\"field_1_28\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_28'>\n                            \n                            <span id='input_1_28_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_28.3' id='input_1_28_3' value=''   aria-required='true'   placeholder='First'  \/>\n                                                    <label for='input_1_28_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_28_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_28.6' id='input_1_28_6' value=''   aria-required='true'   placeholder='Last'  \/>\n                                                    <label for='input_1_28_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_184\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_184'>Relationship to you<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_184' id='input_1_184' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_29\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_29' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_29_1_container' >\n                                        <input type='text' name='input_29.1' id='input_1_29_1' value=''   placeholder='Street address' aria-required='true'    \/>\n                                        <label for='input_1_29_1' id='input_1_29_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_29_2_container' >\n                                        <input type='text' name='input_29.2' id='input_1_29_2' value=''   placeholder='Address line 2'  aria-required='false'   \/>\n                                        <label for='input_1_29_2' id='input_1_29_2_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_29_3_container' >\n                                    <input type='text' name='input_29.3' id='input_1_29_3' value=''   placeholder='Suburb' aria-required='true'    \/>\n                                    <label for='input_1_29_3' id='input_1_29_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Suburb<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_29_4_container' >\n                                        <input type='text' name='input_29.4' id='input_1_29_4' value=''     placeholder='State' aria-required='true'    \/>\n                                        <label for='input_1_29_4' id='input_1_29_4_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_29_5_container' >\n                                    <input type='text' name='input_29.5' id='input_1_29_5' value=''   placeholder='Postcode' aria-required='true'    \/>\n                                    <label for='input_1_29_5' id='input_1_29_5_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Postcode<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_29.6' id='input_1_29_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_31\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_31'>Contact number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_31' id='input_1_31' type='tel' value='' class='small'  placeholder='Home or mobile' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_32\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_32'>Contact number<\/label><div class='ginput_container ginput_container_phone'><input name='input_32' id='input_1_32' type='tel' value='' class='small'  placeholder='Home or mobile'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_33\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_33'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_33' id='input_1_33' type='email' value='' class='small'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_1_34\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Additional contact person<\/h3><\/li><li id=\"field_1_35\" class=\"gfield gfield--type-name field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_35'>\n                            \n                            <span id='input_1_35_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_35.3' id='input_1_35_3' value=''   aria-required='false'   placeholder='First'  \/>\n                                                    <label for='input_1_35_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_35_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_35.6' id='input_1_35_6' value=''   aria-required='false'   placeholder='Last'  \/>\n                                                    <label for='input_1_35_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_36\" class=\"gfield gfield--type-address field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_36' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_36_1_container' >\n                                        <input type='text' name='input_36.1' id='input_1_36_1' value=''   placeholder='Street address' aria-required='false'    \/>\n                                        <label for='input_1_36_1' id='input_1_36_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_36_2_container' >\n                                        <input type='text' name='input_36.2' id='input_1_36_2' value=''   placeholder='Address line 2'  aria-required='false'   \/>\n                                        <label for='input_1_36_2' id='input_1_36_2_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_36_3_container' >\n                                    <input type='text' name='input_36.3' id='input_1_36_3' value=''   placeholder='Suburb' aria-required='false'    \/>\n                                    <label for='input_1_36_3' id='input_1_36_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Suburb<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_36_4_container' >\n                                        <input type='text' name='input_36.4' id='input_1_36_4' value=''     placeholder='State' aria-required='false'    \/>\n                                        <label for='input_1_36_4' id='input_1_36_4_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_36_5_container' >\n                                    <input type='text' name='input_36.5' id='input_1_36_5' value=''   placeholder='Postcode' aria-required='false'    \/>\n                                    <label for='input_1_36_5' id='input_1_36_5_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Postcode<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_36.6' id='input_1_36_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_38\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_38'>Contact number<\/label><div class='ginput_container ginput_container_phone'><input name='input_38' id='input_1_38' type='tel' value='' class='small'  placeholder='Home or mobile'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_39\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_39'>Contact number<\/label><div class='ginput_container ginput_container_phone'><input name='input_39' id='input_1_39' type='tel' value='' class='small'  placeholder='Home or mobile'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_40\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_40'>Relationship to you<\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_1_40' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_1_167' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_1_2_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Save and continue later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_2' class='gform_page' data-js='page-field-id-167' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_41\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Medical details<\/h3><\/li><li id=\"field_1_43\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_43'>Medicare number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_43'>Do not include spaces in the number<\/div><div class='ginput_container ginput_container_text'><input name='input_43' id='input_1_43' type='text' value='' class='small'  aria-describedby=\"gfield_description_1_43\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_45\" class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_45'>Single digit next to your name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_45'>The number that appears before your name on the card<\/div><div class='ginput_container ginput_container_number'><input name='input_45' id='input_1_45' type='text' step='any'   value='' class='small'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_1_45\" \/><\/div><\/li><li id=\"field_1_52\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_52'>Medicare expiry date<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_1_52' type='text' value='' class='small'    placeholder='mm\/yy'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_53\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Private health fund details<\/h3><\/li><li id=\"field_1_54\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you have private health insurance?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_54'>\n\t\t\t<li class='gchoice gchoice_1_54_0'>\n\t\t\t\t<input name='input_54' type='radio' value='Yes'  id='choice_1_54_0'    \/>\n\t\t\t\t<label for='choice_1_54_0' id='label_1_54_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_54_1'>\n\t\t\t\t<input name='input_54' type='radio' value='No'  id='choice_1_54_1'    \/>\n\t\t\t\t<label for='choice_1_54_1' id='label_1_54_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_55\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_55'>Health fund<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_1_55' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_56\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_56'>Health fund membership number<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_1_56' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_57\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Details of entitlement cards<\/h3><\/li><li id=\"field_1_58\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you have a health card?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_58'>\n\t\t\t<li class='gchoice gchoice_1_58_0'>\n\t\t\t\t<input name='input_58' type='radio' value='Yes'  id='choice_1_58_0'    \/>\n\t\t\t\t<label for='choice_1_58_0' id='label_1_58_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_58_1'>\n\t\t\t\t<input name='input_58' type='radio' value='No'  id='choice_1_58_1'    \/>\n\t\t\t\t<label for='choice_1_58_1' id='label_1_58_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_59\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_59'>Health card number<\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_1_59' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_60\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_60'>Health card expiry date<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_1_60' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_61\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you have a pension card?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_61'>\n\t\t\t<li class='gchoice gchoice_1_61_0'>\n\t\t\t\t<input name='input_61' type='radio' value='Yes'  id='choice_1_61_0'    \/>\n\t\t\t\t<label for='choice_1_61_0' id='label_1_61_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_61_1'>\n\t\t\t\t<input name='input_61' type='radio' value='No'  id='choice_1_61_1'    \/>\n\t\t\t\t<label for='choice_1_61_1' id='label_1_61_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_62\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_62'>Pension card number<\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_1_62' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_172\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_172'>Pension card expiry date<\/label><div class='ginput_container ginput_container_text'><input name='input_172' id='input_1_172' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_63\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you have a Veteran&#039;s Affairs (DVA) card?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_63'>\n\t\t\t<li class='gchoice gchoice_1_63_0'>\n\t\t\t\t<input name='input_63' type='radio' value='Yes'  id='choice_1_63_0'    \/>\n\t\t\t\t<label for='choice_1_63_0' id='label_1_63_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_63_1'>\n\t\t\t\t<input name='input_63' type='radio' value='No'  id='choice_1_63_1'    \/>\n\t\t\t\t<label for='choice_1_63_1' id='label_1_63_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_64\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_64'>Veteran&#039;s Affairs card number<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_1_64' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_65\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_65'>Veteran&#039;s Affairs colour<\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_1_65' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_168' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_168' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_1_3_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Save and continue later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_3' class='gform_page' data-js='page-field-id-168' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_68\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>General practitioner details<\/h3><\/li><li id=\"field_1_69\" class=\"gfield gfield--type-name field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name of your GP<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_1_69'>\n                            \n                            <span id='input_1_69_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_69.3' id='input_1_69_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_69_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>GP name<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/li><li id=\"field_1_179\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_179'>Medical Centre<\/label><div class='ginput_container ginput_container_text'><input name='input_179' id='input_1_179' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_70\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_70'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_70' id='input_1_70' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_71\" class=\"gfield gfield--type-address field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_71' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_71_1_container' >\n                                        <input type='text' name='input_71.1' id='input_1_71_1' value=''   placeholder='Street address' aria-required='false'    \/>\n                                        <label for='input_1_71_1' id='input_1_71_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_71_3_container' >\n                                    <input type='text' name='input_71.3' id='input_1_71_3' value=''   placeholder='Suburb' aria-required='false'    \/>\n                                    <label for='input_1_71_3' id='input_1_71_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Suburb<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_71_4_container' >\n                                        <input type='text' name='input_71.4' id='input_1_71_4' value=''     placeholder='State' aria-required='false'    \/>\n                                        <label for='input_1_71_4' id='input_1_71_4_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_71_5_container' >\n                                    <input type='text' name='input_71.5' id='input_1_71_5' value=''   placeholder='Postcode' aria-required='false'    \/>\n                                    <label for='input_1_71_5' id='input_1_71_5_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Postcode<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_71.6' id='input_1_71_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_72\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Antenatal booking information<\/h3><\/li><li id=\"field_1_73\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_73'>Your height (cms)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_1_73' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_74\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_74'>Pre-pregnant weight (kgs)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_1_74' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_75\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_75'>Last menstrual period<\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_1_75' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_76\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you certain your menstrual dates are correct?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_76'>\n\t\t\t<li class='gchoice gchoice_1_76_0'>\n\t\t\t\t<input name='input_76' type='radio' value='Yes'  id='choice_1_76_0'    \/>\n\t\t\t\t<label for='choice_1_76_0' id='label_1_76_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_76_1'>\n\t\t\t\t<input name='input_76' type='radio' value='No'  id='choice_1_76_1'    \/>\n\t\t\t\t<label for='choice_1_76_1' id='label_1_76_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_77\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_77'>Baby&#039;s due date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_77' id='input_1_77' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_77_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_77_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_77' class='gform_hidden' value='https:\/\/metronorth.health.qld.gov.au\/caboolture\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_78\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you had a date scan?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_78'>\n\t\t\t<li class='gchoice gchoice_1_78_0'>\n\t\t\t\t<input name='input_78' type='radio' value='Yes'  id='choice_1_78_0'    \/>\n\t\t\t\t<label for='choice_1_78_0' id='label_1_78_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_78_1'>\n\t\t\t\t<input name='input_78' type='radio' value='No'  id='choice_1_78_1'    \/>\n\t\t\t\t<label for='choice_1_78_1' id='label_1_78_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_180\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Where did you have your date scan?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_180'>\n\t\t\t<li class='gchoice gchoice_1_180_0'>\n\t\t\t\t<input name='input_180' type='radio' value='Queensland Diagnostic Imaging'  id='choice_1_180_0'    \/>\n\t\t\t\t<label for='choice_1_180_0' id='label_1_180_0' class='gform-field-label gform-field-label--type-inline'>Queensland Diagnostic Imaging<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_180_1'>\n\t\t\t\t<input name='input_180' type='radio' value='Southern X-ray'  id='choice_1_180_1'    \/>\n\t\t\t\t<label for='choice_1_180_1' id='label_1_180_1' class='gform-field-label gform-field-label--type-inline'>Southern X-ray<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_180_2'>\n\t\t\t\t<input name='input_180' type='radio' value='Lime'  id='choice_1_180_2'    \/>\n\t\t\t\t<label for='choice_1_180_2' id='label_1_180_2' class='gform-field-label gform-field-label--type-inline'>Lime<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_180_3'>\n\t\t\t\t<input name='input_180' type='radio' value='gf_other_choice'  id='choice_1_180_3'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_1_180_other' name='input_180_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_81\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you had a blood test with your GP?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_81'>\n\t\t\t<li class='gchoice gchoice_1_81_0'>\n\t\t\t\t<input name='input_81' type='radio' value='Yes'  id='choice_1_81_0'    \/>\n\t\t\t\t<label for='choice_1_81_0' id='label_1_81_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_81_1'>\n\t\t\t\t<input name='input_81' type='radio' value='No'  id='choice_1_81_1'    \/>\n\t\t\t\t<label for='choice_1_81_1' id='label_1_81_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_181\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >With which pathologist?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_181'>\n\t\t\t<li class='gchoice gchoice_1_181_0'>\n\t\t\t\t<input name='input_181' type='radio' value='QML'  id='choice_1_181_0'    \/>\n\t\t\t\t<label for='choice_1_181_0' id='label_1_181_0' class='gform-field-label gform-field-label--type-inline'>QML<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_181_1'>\n\t\t\t\t<input name='input_181' type='radio' value='S&amp;N'  id='choice_1_181_1'    \/>\n\t\t\t\t<label for='choice_1_181_1' id='label_1_181_1' class='gform-field-label gform-field-label--type-inline'>S&amp;N<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_181_2'>\n\t\t\t\t<input name='input_181' type='radio' value='Health scope'  id='choice_1_181_2'    \/>\n\t\t\t\t<label for='choice_1_181_2' id='label_1_181_2' class='gform-field-label gform-field-label--type-inline'>Health scope<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_181_3'>\n\t\t\t\t<input name='input_181' type='radio' value='gf_other_choice'  id='choice_1_181_3'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_1_181_other' name='input_181_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_173\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Has your GP arranged a Nuchal Translucency Scan for you?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_173'>\n\t\t\t<li class='gchoice gchoice_1_173_0'>\n\t\t\t\t<input name='input_173' type='radio' value='Yes'  id='choice_1_173_0'    \/>\n\t\t\t\t<label for='choice_1_173_0' id='label_1_173_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_173_1'>\n\t\t\t\t<input name='input_173' type='radio' value='No'  id='choice_1_173_1'    \/>\n\t\t\t\t<label for='choice_1_173_1' id='label_1_173_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_82\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_82'>Date of scan<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_82' id='input_1_82' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_82_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_82_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_82' class='gform_hidden' value='https:\/\/metronorth.health.qld.gov.au\/caboolture\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_182\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Where did you have your Nuchal Translucency Scan?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_182'>\n\t\t\t<li class='gchoice gchoice_1_182_0'>\n\t\t\t\t<input name='input_182' type='radio' value='Queensland Diagnostic Imaging'  id='choice_1_182_0'    \/>\n\t\t\t\t<label for='choice_1_182_0' id='label_1_182_0' class='gform-field-label gform-field-label--type-inline'>Queensland Diagnostic Imaging<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_182_1'>\n\t\t\t\t<input name='input_182' type='radio' value='Southern X-ray'  id='choice_1_182_1'    \/>\n\t\t\t\t<label for='choice_1_182_1' id='label_1_182_1' class='gform-field-label gform-field-label--type-inline'>Southern X-ray<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_182_2'>\n\t\t\t\t<input name='input_182' type='radio' value='Lime'  id='choice_1_182_2'    \/>\n\t\t\t\t<label for='choice_1_182_2' id='label_1_182_2' class='gform-field-label gform-field-label--type-inline'>Lime<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_182_3'>\n\t\t\t\t<input name='input_182' type='radio' value='gf_other_choice'  id='choice_1_182_3'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_1_182_other' name='input_182_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_85\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Has an immediate family member (mother, father, sister or brother) had a child with Downs Syndrome?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_85'>\n\t\t\t<li class='gchoice gchoice_1_85_0'>\n\t\t\t\t<input name='input_85' type='radio' value='Yes'  id='choice_1_85_0'    \/>\n\t\t\t\t<label for='choice_1_85_0' id='label_1_85_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_85_1'>\n\t\t\t\t<input name='input_85' type='radio' value='No'  id='choice_1_85_1'    \/>\n\t\t\t\t<label for='choice_1_85_1' id='label_1_85_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_86\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_86'>Details<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_86' id='input_1_86' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_87\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >If you are over 20 weeks pregnant, have you had your 18-20 week Morphology scan?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_87'>\n\t\t\t<li class='gchoice gchoice_1_87_0'>\n\t\t\t\t<input name='input_87' type='radio' value='Yes'  id='choice_1_87_0'    \/>\n\t\t\t\t<label for='choice_1_87_0' id='label_1_87_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_87_1'>\n\t\t\t\t<input name='input_87' type='radio' value='No'  id='choice_1_87_1'    \/>\n\t\t\t\t<label for='choice_1_87_1' id='label_1_87_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_87_2'>\n\t\t\t\t<input name='input_87' type='radio' value='Earlier than 20 weeks'  id='choice_1_87_2'    \/>\n\t\t\t\t<label for='choice_1_87_2' id='label_1_87_2' class='gform-field-label gform-field-label--type-inline'>Earlier than 20 weeks<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_88\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_88'>Date of scan<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_88' id='input_1_88' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_88_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_88_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_88' class='gform_hidden' value='https:\/\/metronorth.health.qld.gov.au\/caboolture\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_183\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Where did you have your Morphology scan?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_183'>\n\t\t\t<li class='gchoice gchoice_1_183_0'>\n\t\t\t\t<input name='input_183' type='radio' value='Queensland Diagnostic Imaging'  id='choice_1_183_0'    \/>\n\t\t\t\t<label for='choice_1_183_0' id='label_1_183_0' class='gform-field-label gform-field-label--type-inline'>Queensland Diagnostic Imaging<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_183_1'>\n\t\t\t\t<input name='input_183' type='radio' value='Southern X-ray'  id='choice_1_183_1'    \/>\n\t\t\t\t<label for='choice_1_183_1' id='label_1_183_1' class='gform-field-label gform-field-label--type-inline'>Southern X-ray<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_183_2'>\n\t\t\t\t<input name='input_183' type='radio' value='Lime'  id='choice_1_183_2'    \/>\n\t\t\t\t<label for='choice_1_183_2' id='label_1_183_2' class='gform-field-label gform-field-label--type-inline'>Lime<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_183_3'>\n\t\t\t\t<input name='input_183' type='radio' value='gf_other_choice'  id='choice_1_183_3'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_1_183_other' name='input_183_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_91\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you transferring from another hospital?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_91'>\n\t\t\t<li class='gchoice gchoice_1_91_0'>\n\t\t\t\t<input name='input_91' type='radio' value='Yes'  id='choice_1_91_0'    \/>\n\t\t\t\t<label for='choice_1_91_0' id='label_1_91_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_91_1'>\n\t\t\t\t<input name='input_91' type='radio' value='No'  id='choice_1_91_1'    \/>\n\t\t\t\t<label for='choice_1_91_1' id='label_1_91_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_92\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_92'>Which hospital?<\/label><div class='gfield_description' id='gfield_description_1_92'>The name of the hospital you are transferring from<\/div><div class='ginput_container ginput_container_text'><input name='input_92' id='input_1_92' type='text' value='' class='medium'  aria-describedby=\"gfield_description_1_92\"    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_93\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you have a Queensland Government Pregnancy Health Record (orange booklet)?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_93'>\n\t\t\t<li class='gchoice gchoice_1_93_0'>\n\t\t\t\t<input name='input_93' type='radio' value='Yes'  id='choice_1_93_0'    \/>\n\t\t\t\t<label for='choice_1_93_0' id='label_1_93_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_93_1'>\n\t\t\t\t<input name='input_93' type='radio' value='No'  id='choice_1_93_1'    \/>\n\t\t\t\t<label for='choice_1_93_1' id='label_1_93_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_93_2'>\n\t\t\t\t<input name='input_93' type='radio' value='Unsure'  id='choice_1_93_2'    \/>\n\t\t\t\t<label for='choice_1_93_2' id='label_1_93_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_169' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_169' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_1_4_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Save and continue later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_4' class='gform_page' data-js='page-field-id-169' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_94\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Your medical history<\/h3>\n<p>Do you or have you ever had a:<\/p><\/li><li id=\"field_1_95\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Heart condition<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_95'>\n\t\t\t<li class='gchoice gchoice_1_95_0'>\n\t\t\t\t<input name='input_95' type='radio' value='Yes'  id='choice_1_95_0'    \/>\n\t\t\t\t<label for='choice_1_95_0' id='label_1_95_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_95_1'>\n\t\t\t\t<input name='input_95' type='radio' value='No'  id='choice_1_95_1'    \/>\n\t\t\t\t<label for='choice_1_95_1' id='label_1_95_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_96\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_96'>Details<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_96' id='input_1_96' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_97\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >High blood pressure<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_97'>\n\t\t\t<li class='gchoice gchoice_1_97_0'>\n\t\t\t\t<input name='input_97' type='radio' value='Yes'  id='choice_1_97_0'    \/>\n\t\t\t\t<label for='choice_1_97_0' id='label_1_97_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_97_1'>\n\t\t\t\t<input name='input_97' type='radio' value='No'  id='choice_1_97_1'    \/>\n\t\t\t\t<label for='choice_1_97_1' id='label_1_97_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_98\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_98'>Details<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_98' id='input_1_98' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_99\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Thyroid condition<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_99'>\n\t\t\t<li class='gchoice gchoice_1_99_0'>\n\t\t\t\t<input name='input_99' type='radio' value='Yes'  id='choice_1_99_0'    \/>\n\t\t\t\t<label for='choice_1_99_0' id='label_1_99_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_99_1'>\n\t\t\t\t<input name='input_99' type='radio' value='No'  id='choice_1_99_1'    \/>\n\t\t\t\t<label for='choice_1_99_1' id='label_1_99_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_100\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_100'>Details<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_100' id='input_1_100' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_193\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Personal History of Type 1 or 2 Diabetes<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_193'>\n\t\t\t<li class='gchoice gchoice_1_193_0'>\n\t\t\t\t<input name='input_193' type='radio' value='No'  id='choice_1_193_0'    \/>\n\t\t\t\t<label for='choice_1_193_0' id='label_1_193_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_193_1'>\n\t\t\t\t<input name='input_193' type='radio' value='Type 1 Diabetes'  id='choice_1_193_1'    \/>\n\t\t\t\t<label for='choice_1_193_1' id='label_1_193_1' class='gform-field-label gform-field-label--type-inline'>Type 1 Diabetes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_193_2'>\n\t\t\t\t<input name='input_193' type='radio' value='Type 2 Diabetes'  id='choice_1_193_2'    \/>\n\t\t\t\t<label for='choice_1_193_2' id='label_1_193_2' class='gform-field-label gform-field-label--type-inline'>Type 2 Diabetes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_198\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_198'>If Type 1 or Type 2 diabetes, please provide your 8-digit National Diabetes Service Scheme (NDSS) number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_198' id='input_1_198' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_194\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >If Type 2 Diabetes, specify your treatment<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_194'>\n\t\t\t<li class='gchoice gchoice_1_194_0'>\n\t\t\t\t<input name='input_194' type='radio' value='Insulin'  id='choice_1_194_0'    \/>\n\t\t\t\t<label for='choice_1_194_0' id='label_1_194_0' class='gform-field-label gform-field-label--type-inline'>Insulin<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_194_1'>\n\t\t\t\t<input name='input_194' type='radio' value='Metformin'  id='choice_1_194_1'    \/>\n\t\t\t\t<label for='choice_1_194_1' id='label_1_194_1' class='gform-field-label gform-field-label--type-inline'>Metformin<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_194_2'>\n\t\t\t\t<input name='input_194' type='radio' value='Insulin and Metformin'  id='choice_1_194_2'    \/>\n\t\t\t\t<label for='choice_1_194_2' id='label_1_194_2' class='gform-field-label gform-field-label--type-inline'>Insulin and Metformin<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_194_3'>\n\t\t\t\t<input name='input_194' type='radio' value='Diet alone'  id='choice_1_194_3'    \/>\n\t\t\t\t<label for='choice_1_194_3' id='label_1_194_3' class='gform-field-label gform-field-label--type-inline'>Diet alone<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_101\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Family history of Type 1 or Type 2 diabetes<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_101'>\n\t\t\t<li class='gchoice gchoice_1_101_0'>\n\t\t\t\t<input name='input_101' type='radio' value='No'  id='choice_1_101_0'    \/>\n\t\t\t\t<label for='choice_1_101_0' id='label_1_101_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_101_1'>\n\t\t\t\t<input name='input_101' type='radio' value='Type 1 Diabetes'  id='choice_1_101_1'    \/>\n\t\t\t\t<label for='choice_1_101_1' id='label_1_101_1' class='gform-field-label gform-field-label--type-inline'>Type 1 Diabetes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_101_2'>\n\t\t\t\t<input name='input_101' type='radio' value='Type 2 Diabetes'  id='choice_1_101_2'    \/>\n\t\t\t\t<label for='choice_1_101_2' id='label_1_101_2' class='gform-field-label gform-field-label--type-inline'>Type 2 Diabetes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_103\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Gestational Diabetes in a previous pregnancy<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_103'>\n\t\t\t<li class='gchoice gchoice_1_103_0'>\n\t\t\t\t<input name='input_103' type='radio' value='Yes'  id='choice_1_103_0'    \/>\n\t\t\t\t<label for='choice_1_103_0' id='label_1_103_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_103_1'>\n\t\t\t\t<input name='input_103' type='radio' value='No'  id='choice_1_103_1'    \/>\n\t\t\t\t<label for='choice_1_103_1' id='label_1_103_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_195\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >If yes, what was your treatment<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_195'>\n\t\t\t<li class='gchoice gchoice_1_195_0'>\n\t\t\t\t<input name='input_195' type='radio' value='Insulin'  id='choice_1_195_0'    \/>\n\t\t\t\t<label for='choice_1_195_0' id='label_1_195_0' class='gform-field-label gform-field-label--type-inline'>Insulin<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_195_1'>\n\t\t\t\t<input name='input_195' type='radio' value='Metformin only'  id='choice_1_195_1'    \/>\n\t\t\t\t<label for='choice_1_195_1' id='label_1_195_1' class='gform-field-label gform-field-label--type-inline'>Metformin only<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_195_2'>\n\t\t\t\t<input name='input_195' type='radio' value='Diet'  id='choice_1_195_2'    \/>\n\t\t\t\t<label for='choice_1_195_2' id='label_1_195_2' class='gform-field-label gform-field-label--type-inline'>Diet<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_105\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Kidney disorder<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_105'>\n\t\t\t<li class='gchoice gchoice_1_105_0'>\n\t\t\t\t<input name='input_105' type='radio' value='Yes'  id='choice_1_105_0'    \/>\n\t\t\t\t<label for='choice_1_105_0' id='label_1_105_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_105_1'>\n\t\t\t\t<input name='input_105' type='radio' value='No'  id='choice_1_105_1'    \/>\n\t\t\t\t<label for='choice_1_105_1' id='label_1_105_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_106\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_106'>Details<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_106' id='input_1_106' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_107\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Blood clotting disorder<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_107'>\n\t\t\t<li class='gchoice gchoice_1_107_0'>\n\t\t\t\t<input name='input_107' type='radio' value='Yes'  id='choice_1_107_0'    \/>\n\t\t\t\t<label for='choice_1_107_0' id='label_1_107_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_107_1'>\n\t\t\t\t<input name='input_107' type='radio' value='No'  id='choice_1_107_1'    \/>\n\t\t\t\t<label for='choice_1_107_1' id='label_1_107_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_108\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_108'>Details<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_108' id='input_1_108' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_109\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Auto immune disorder<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_109'>\n\t\t\t<li class='gchoice gchoice_1_109_0'>\n\t\t\t\t<input name='input_109' type='radio' value='Yes'  id='choice_1_109_0'    \/>\n\t\t\t\t<label for='choice_1_109_0' id='label_1_109_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_109_1'>\n\t\t\t\t<input name='input_109' type='radio' value='No'  id='choice_1_109_1'    \/>\n\t\t\t\t<label for='choice_1_109_1' id='label_1_109_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_110\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_110'>Details<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_110' id='input_1_110' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_111\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Hepatitis<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_111'>\n\t\t\t<li class='gchoice gchoice_1_111_0'>\n\t\t\t\t<input name='input_111' type='radio' value='Yes'  id='choice_1_111_0'    \/>\n\t\t\t\t<label for='choice_1_111_0' id='label_1_111_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_111_1'>\n\t\t\t\t<input name='input_111' type='radio' value='No'  id='choice_1_111_1'    \/>\n\t\t\t\t<label for='choice_1_111_1' id='label_1_111_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_112\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_112'>Details<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_112' id='input_1_112' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_113\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Epilepsy<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_113'>\n\t\t\t<li class='gchoice gchoice_1_113_0'>\n\t\t\t\t<input name='input_113' type='radio' value='Yes'  id='choice_1_113_0'    \/>\n\t\t\t\t<label for='choice_1_113_0' id='label_1_113_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_113_1'>\n\t\t\t\t<input name='input_113' type='radio' value='No'  id='choice_1_113_1'    \/>\n\t\t\t\t<label for='choice_1_113_1' id='label_1_113_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_114\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_114'>Details<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_114' id='input_1_114' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_115\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Mental health disorder<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_115'>\n\t\t\t<li class='gchoice gchoice_1_115_0'>\n\t\t\t\t<input name='input_115' type='radio' value='Yes'  id='choice_1_115_0'    \/>\n\t\t\t\t<label for='choice_1_115_0' id='label_1_115_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_115_1'>\n\t\t\t\t<input name='input_115' type='radio' value='No'  id='choice_1_115_1'    \/>\n\t\t\t\t<label for='choice_1_115_1' id='label_1_115_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_116\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_116'>Details<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_116' id='input_1_116' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_117\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Abnormal pap smear<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_117'>\n\t\t\t<li class='gchoice gchoice_1_117_0'>\n\t\t\t\t<input name='input_117' type='radio' value='Yes'  id='choice_1_117_0'    \/>\n\t\t\t\t<label for='choice_1_117_0' id='label_1_117_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_117_1'>\n\t\t\t\t<input name='input_117' type='radio' value='No'  id='choice_1_117_1'    \/>\n\t\t\t\t<label for='choice_1_117_1' id='label_1_117_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_118\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_118'>Details<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_118' id='input_1_118' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_185\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you ever had an MRO (multi-resistant organism) infection (eg MRSA)?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_185'>\n\t\t\t<li class='gchoice gchoice_1_185_0'>\n\t\t\t\t<input name='input_185' type='radio' value='Yes'  id='choice_1_185_0'    \/>\n\t\t\t\t<label for='choice_1_185_0' id='label_1_185_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_185_1'>\n\t\t\t\t<input name='input_185' type='radio' value='No'  id='choice_1_185_1'    \/>\n\t\t\t\t<label for='choice_1_185_1' id='label_1_185_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_185_2'>\n\t\t\t\t<input name='input_185' type='radio' value='Unsure'  id='choice_1_185_2'    \/>\n\t\t\t\t<label for='choice_1_185_2' id='label_1_185_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_186\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_186'>Details<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_186' id='input_1_186' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_187\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >In the past 3\u20136 months have you used any prescribed, non-prescribed or herbal drugs?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_187'>\n\t\t\t<li class='gchoice gchoice_1_187_0'>\n\t\t\t\t<input name='input_187' type='radio' value='Yes'  id='choice_1_187_0'    \/>\n\t\t\t\t<label for='choice_1_187_0' id='label_1_187_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_187_1'>\n\t\t\t\t<input name='input_187' type='radio' value='No'  id='choice_1_187_1'    \/>\n\t\t\t\t<label for='choice_1_187_1' id='label_1_187_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_188\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_188'>Details<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_188' id='input_1_188' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_189\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >During this pregnancy How often have you had a drink containing alcohol in it?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_189'>\n\t\t\t<li class='gchoice gchoice_1_189_0'>\n\t\t\t\t<input name='input_189' type='radio' value='Only prior to confirmation of pregnancy; have since stopped'  id='choice_1_189_0'    \/>\n\t\t\t\t<label for='choice_1_189_0' id='label_1_189_0' class='gform-field-label gform-field-label--type-inline'>Only prior to confirmation of pregnancy; have since stopped<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_189_1'>\n\t\t\t\t<input name='input_189' type='radio' value='Never'  id='choice_1_189_1'    \/>\n\t\t\t\t<label for='choice_1_189_1' id='label_1_189_1' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_189_2'>\n\t\t\t\t<input name='input_189' type='radio' value='Monthly or less'  id='choice_1_189_2'    \/>\n\t\t\t\t<label for='choice_1_189_2' id='label_1_189_2' class='gform-field-label gform-field-label--type-inline'>Monthly or less<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_189_3'>\n\t\t\t\t<input name='input_189' type='radio' value='2 to 4 times per month'  id='choice_1_189_3'    \/>\n\t\t\t\t<label for='choice_1_189_3' id='label_1_189_3' class='gform-field-label gform-field-label--type-inline'>2 to 4 times per month<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_189_4'>\n\t\t\t\t<input name='input_189' type='radio' value='2 to 3 times per week'  id='choice_1_189_4'    \/>\n\t\t\t\t<label for='choice_1_189_4' id='label_1_189_4' class='gform-field-label gform-field-label--type-inline'>2 to 3 times per week<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_189_5'>\n\t\t\t\t<input name='input_189' type='radio' value='4 or more times per week'  id='choice_1_189_5'    \/>\n\t\t\t\t<label for='choice_1_189_5' id='label_1_189_5' class='gform-field-label gform-field-label--type-inline'>4 or more times per week<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_190\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Which of these statements best describes your current smoking?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_190'>\n\t\t\t<li class='gchoice gchoice_1_190_0'>\n\t\t\t\t<input name='input_190' type='radio' value='I have never smoked'  id='choice_1_190_0'    \/>\n\t\t\t\t<label for='choice_1_190_0' id='label_1_190_0' class='gform-field-label gform-field-label--type-inline'>I have never smoked<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_190_1'>\n\t\t\t\t<input name='input_190' type='radio' value='I smoke daily now, about the same as before finding out I was pregnant'  id='choice_1_190_1'    \/>\n\t\t\t\t<label for='choice_1_190_1' id='label_1_190_1' class='gform-field-label gform-field-label--type-inline'>I smoke daily now, about the same as before finding out I was pregnant<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_190_2'>\n\t\t\t\t<input name='input_190' type='radio' value='I smoke daily now, but I&#039;ve cut down since finding out I was pregnant'  id='choice_1_190_2'    \/>\n\t\t\t\t<label for='choice_1_190_2' id='label_1_190_2' class='gform-field-label gform-field-label--type-inline'>I smoke daily now, but I've cut down since finding out I was pregnant<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_190_3'>\n\t\t\t\t<input name='input_190' type='radio' value='I smoke every once in awhile'  id='choice_1_190_3'    \/>\n\t\t\t\t<label for='choice_1_190_3' id='label_1_190_3' class='gform-field-label gform-field-label--type-inline'>I smoke every once in awhile<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_190_4'>\n\t\t\t\t<input name='input_190' type='radio' value='I quit smoking since finding out I was pregnant'  id='choice_1_190_4'    \/>\n\t\t\t\t<label for='choice_1_190_4' id='label_1_190_4' class='gform-field-label gform-field-label--type-inline'>I quit smoking since finding out I was pregnant<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_190_5'>\n\t\t\t\t<input name='input_190' type='radio' value='I wasn\u2019t smoking around the time I found out I was pregnant - I had smoked within the last 12 months'  id='choice_1_190_5'    \/>\n\t\t\t\t<label for='choice_1_190_5' id='label_1_190_5' class='gform-field-label gform-field-label--type-inline'>I wasn\u2019t smoking around the time I found out I was pregnant - I had smoked within the last 12 months<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_190_6'>\n\t\t\t\t<input name='input_190' type='radio' value='Previous smoker'  id='choice_1_190_6'    \/>\n\t\t\t\t<label for='choice_1_190_6' id='label_1_190_6' class='gform-field-label gform-field-label--type-inline'>Previous smoker<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_191\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_191'>Number of cigarettes per day<\/label><div class='ginput_container ginput_container_text'><input name='input_191' id='input_1_191' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_119\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_119'>Any other conditions<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_119' id='input_1_119' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_120\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you ever had a Lletz Procedure or a cone biopsy?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_120'>\n\t\t\t<li class='gchoice gchoice_1_120_0'>\n\t\t\t\t<input name='input_120' type='radio' value='Yes'  id='choice_1_120_0'    \/>\n\t\t\t\t<label for='choice_1_120_0' id='label_1_120_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_120_1'>\n\t\t\t\t<input name='input_120' type='radio' value='No'  id='choice_1_120_1'    \/>\n\t\t\t\t<label for='choice_1_120_1' id='label_1_120_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_120_2'>\n\t\t\t\t<input name='input_120' type='radio' value='Unsure'  id='choice_1_120_2'    \/>\n\t\t\t\t<label for='choice_1_120_2' id='label_1_120_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_170' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_170' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_1_5_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Save and continue later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_5' class='gform_page' data-js='page-field-id-170' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_121\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Obstetric history<\/h3>\n<p>Have you ever had a:<\/p><\/li><li id=\"field_1_122\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Miscarriage<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_122'>\n\t\t\t<li class='gchoice gchoice_1_122_0'>\n\t\t\t\t<input name='input_122' type='radio' value='Yes'  id='choice_1_122_0'    \/>\n\t\t\t\t<label for='choice_1_122_0' id='label_1_122_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_122_1'>\n\t\t\t\t<input name='input_122' type='radio' value='No'  id='choice_1_122_1'    \/>\n\t\t\t\t<label for='choice_1_122_1' id='label_1_122_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_123\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_123'>How many?<\/label><div class='ginput_container ginput_container_number'><input name='input_123' id='input_1_123' type='text' step='any'   value='' class='small'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_124\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Molar pregnancy<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_124'>\n\t\t\t<li class='gchoice gchoice_1_124_0'>\n\t\t\t\t<input name='input_124' type='radio' value='Yes'  id='choice_1_124_0'    \/>\n\t\t\t\t<label for='choice_1_124_0' id='label_1_124_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_124_1'>\n\t\t\t\t<input name='input_124' type='radio' value='No'  id='choice_1_124_1'    \/>\n\t\t\t\t<label for='choice_1_124_1' id='label_1_124_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_125\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_125'>Date of molar pregnancy<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_125' id='input_1_125' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_125_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_125_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_125' class='gform_hidden' value='https:\/\/metronorth.health.qld.gov.au\/caboolture\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_126\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Is this an IVF assisted pregnancy?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_126'>\n\t\t\t<li class='gchoice gchoice_1_126_0'>\n\t\t\t\t<input name='input_126' type='radio' value='Yes'  id='choice_1_126_0'    \/>\n\t\t\t\t<label for='choice_1_126_0' id='label_1_126_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_126_1'>\n\t\t\t\t<input name='input_126' type='radio' value='No'  id='choice_1_126_1'    \/>\n\t\t\t\t<label for='choice_1_126_1' id='label_1_126_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_127\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_127'>Details<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_127' id='input_1_127' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_128\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Premature labour<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_128'>\n\t\t\t<li class='gchoice gchoice_1_128_0'>\n\t\t\t\t<input name='input_128' type='radio' value='Yes'  id='choice_1_128_0'    \/>\n\t\t\t\t<label for='choice_1_128_0' id='label_1_128_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_128_1'>\n\t\t\t\t<input name='input_128' type='radio' value='No'  id='choice_1_128_1'    \/>\n\t\t\t\t<label for='choice_1_128_1' id='label_1_128_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_129\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_129'>Details<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_129' id='input_1_129' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_130\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Premature birth (&lt;37 weeks)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_130'>\n\t\t\t<li class='gchoice gchoice_1_130_0'>\n\t\t\t\t<input name='input_130' type='radio' value='Yes'  id='choice_1_130_0'    \/>\n\t\t\t\t<label for='choice_1_130_0' id='label_1_130_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_130_1'>\n\t\t\t\t<input name='input_130' type='radio' value='No'  id='choice_1_130_1'    \/>\n\t\t\t\t<label for='choice_1_130_1' id='label_1_130_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_131\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_131'>Details<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_131' id='input_1_131' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_132\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Cholestasis in pregnancy<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_132'>\n\t\t\t<li class='gchoice gchoice_1_132_0'>\n\t\t\t\t<input name='input_132' type='radio' value='Yes'  id='choice_1_132_0'    \/>\n\t\t\t\t<label for='choice_1_132_0' id='label_1_132_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_132_1'>\n\t\t\t\t<input name='input_132' type='radio' value='No'  id='choice_1_132_1'    \/>\n\t\t\t\t<label for='choice_1_132_1' id='label_1_132_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_133\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_133'>Details<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_133' id='input_1_133' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_134\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >A baby &lt;2500 grams<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_134'>\n\t\t\t<li class='gchoice gchoice_1_134_0'>\n\t\t\t\t<input name='input_134' type='radio' value='Yes'  id='choice_1_134_0'    \/>\n\t\t\t\t<label for='choice_1_134_0' id='label_1_134_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_134_1'>\n\t\t\t\t<input name='input_134' type='radio' value='No'  id='choice_1_134_1'    \/>\n\t\t\t\t<label for='choice_1_134_1' id='label_1_134_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_135\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_135'>Details<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_135' id='input_1_135' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_136\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >A baby &gt;4500 grams<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_136'>\n\t\t\t<li class='gchoice gchoice_1_136_0'>\n\t\t\t\t<input name='input_136' type='radio' value='Yes'  id='choice_1_136_0'    \/>\n\t\t\t\t<label for='choice_1_136_0' id='label_1_136_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_136_1'>\n\t\t\t\t<input name='input_136' type='radio' value='No'  id='choice_1_136_1'    \/>\n\t\t\t\t<label for='choice_1_136_1' id='label_1_136_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_137\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_137'>Details<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_137' id='input_1_137' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_138\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >High blood pressure in pregnancy<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_138'>\n\t\t\t<li class='gchoice gchoice_1_138_0'>\n\t\t\t\t<input name='input_138' type='radio' value='Yes'  id='choice_1_138_0'    \/>\n\t\t\t\t<label for='choice_1_138_0' id='label_1_138_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_138_1'>\n\t\t\t\t<input name='input_138' type='radio' value='No'  id='choice_1_138_1'    \/>\n\t\t\t\t<label for='choice_1_138_1' id='label_1_138_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_139\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_139'>Details<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_139' id='input_1_139' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_140\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you had a previous caesarean section?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_140'>\n\t\t\t<li class='gchoice gchoice_1_140_0'>\n\t\t\t\t<input name='input_140' type='radio' value='Yes'  id='choice_1_140_0'    \/>\n\t\t\t\t<label for='choice_1_140_0' id='label_1_140_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_140_1'>\n\t\t\t\t<input name='input_140' type='radio' value='No'  id='choice_1_140_1'    \/>\n\t\t\t\t<label for='choice_1_140_1' id='label_1_140_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_141\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_141'>Details<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_141' id='input_1_141' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_142\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you considering a vaginal birth after caesarean (VBAC)?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_142'>\n\t\t\t<li class='gchoice gchoice_1_142_0'>\n\t\t\t\t<input name='input_142' type='radio' value='Yes'  id='choice_1_142_0'    \/>\n\t\t\t\t<label for='choice_1_142_0' id='label_1_142_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_142_1'>\n\t\t\t\t<input name='input_142' type='radio' value='No'  id='choice_1_142_1'    \/>\n\t\t\t\t<label for='choice_1_142_1' id='label_1_142_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_143\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_143'>Details<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_143' id='input_1_143' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_144\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >If you have had a previous caesarean section, do you want an elective caesarean section this pregnancy?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_144'>\n\t\t\t<li class='gchoice gchoice_1_144_0'>\n\t\t\t\t<input name='input_144' type='radio' value='Yes'  id='choice_1_144_0'    \/>\n\t\t\t\t<label for='choice_1_144_0' id='label_1_144_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_144_1'>\n\t\t\t\t<input name='input_144' type='radio' value='No'  id='choice_1_144_1'    \/>\n\t\t\t\t<label for='choice_1_144_1' id='label_1_144_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_145\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_145'>Details<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_145' id='input_1_145' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_146\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Previous birth complications<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_146'>\n\t\t\t<li class='gchoice gchoice_1_146_0'>\n\t\t\t\t<input name='input_146' type='radio' value='Yes'  id='choice_1_146_0'    \/>\n\t\t\t\t<label for='choice_1_146_0' id='label_1_146_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_146_1'>\n\t\t\t\t<input name='input_146' type='radio' value='No'  id='choice_1_146_1'    \/>\n\t\t\t\t<label for='choice_1_146_1' id='label_1_146_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_147\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_147'>Details<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_147' id='input_1_147' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_148\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Large blood loss<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_148'>\n\t\t\t<li class='gchoice gchoice_1_148_0'>\n\t\t\t\t<input name='input_148' type='radio' value='Yes'  id='choice_1_148_0'    \/>\n\t\t\t\t<label for='choice_1_148_0' id='label_1_148_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_148_1'>\n\t\t\t\t<input name='input_148' type='radio' value='No'  id='choice_1_148_1'    \/>\n\t\t\t\t<label for='choice_1_148_1' id='label_1_148_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_149\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Shoulder dystocia?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_149'>\n\t\t\t<li class='gchoice gchoice_1_149_0'>\n\t\t\t\t<input name='input_149' type='radio' value='Yes'  id='choice_1_149_0'    \/>\n\t\t\t\t<label for='choice_1_149_0' id='label_1_149_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_149_1'>\n\t\t\t\t<input name='input_149' type='radio' value='No'  id='choice_1_149_1'    \/>\n\t\t\t\t<label for='choice_1_149_1' id='label_1_149_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_150\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Infection<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_150'>\n\t\t\t<li class='gchoice gchoice_1_150_0'>\n\t\t\t\t<input name='input_150' type='radio' value='Yes'  id='choice_1_150_0'    \/>\n\t\t\t\t<label for='choice_1_150_0' id='label_1_150_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_150_1'>\n\t\t\t\t<input name='input_150' type='radio' value='No'  id='choice_1_150_1'    \/>\n\t\t\t\t<label for='choice_1_150_1' id='label_1_150_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_151\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Retained placenta<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_151'>\n\t\t\t<li class='gchoice gchoice_1_151_0'>\n\t\t\t\t<input name='input_151' type='radio' value='Yes'  id='choice_1_151_0'    \/>\n\t\t\t\t<label for='choice_1_151_0' id='label_1_151_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_151_1'>\n\t\t\t\t<input name='input_151' type='radio' value='No'  id='choice_1_151_1'    \/>\n\t\t\t\t<label for='choice_1_151_1' id='label_1_151_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_152\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Admission to  the Intensive Care Unit or Critical Care Unit<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_152'>\n\t\t\t<li class='gchoice gchoice_1_152_0'>\n\t\t\t\t<input name='input_152' type='radio' value='Yes'  id='choice_1_152_0'    \/>\n\t\t\t\t<label for='choice_1_152_0' id='label_1_152_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_152_1'>\n\t\t\t\t<input name='input_152' type='radio' value='No'  id='choice_1_152_1'    \/>\n\t\t\t\t<label for='choice_1_152_1' id='label_1_152_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_153\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >3rd or 4th degree tear that was repaired in the operating theatre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_153'>\n\t\t\t<li class='gchoice gchoice_1_153_0'>\n\t\t\t\t<input name='input_153' type='radio' value='Yes'  id='choice_1_153_0'    \/>\n\t\t\t\t<label for='choice_1_153_0' id='label_1_153_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_153_1'>\n\t\t\t\t<input name='input_153' type='radio' value='No'  id='choice_1_153_1'    \/>\n\t\t\t\t<label for='choice_1_153_1' id='label_1_153_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_154\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >DVT (deep vein thrombosis) or blood clot<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_154'>\n\t\t\t<li class='gchoice gchoice_1_154_0'>\n\t\t\t\t<input name='input_154' type='radio' value='Yes'  id='choice_1_154_0'    \/>\n\t\t\t\t<label for='choice_1_154_0' id='label_1_154_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_154_1'>\n\t\t\t\t<input name='input_154' type='radio' value='No'  id='choice_1_154_1'    \/>\n\t\t\t\t<label for='choice_1_154_1' id='label_1_154_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_155\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >A baby die in pregnancy or at birth<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_155'>\n\t\t\t<li class='gchoice gchoice_1_155_0'>\n\t\t\t\t<input name='input_155' type='radio' value='Yes'  id='choice_1_155_0'    \/>\n\t\t\t\t<label for='choice_1_155_0' id='label_1_155_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_155_1'>\n\t\t\t\t<input name='input_155' type='radio' value='No'  id='choice_1_155_1'    \/>\n\t\t\t\t<label for='choice_1_155_1' id='label_1_155_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_157\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_157'>Date of death<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_157' id='input_1_157' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_157_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_157_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_157' class='gform_hidden' value='https:\/\/metronorth.health.qld.gov.au\/caboolture\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_158\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you expecting a multiple birth?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_158'>\n\t\t\t<li class='gchoice gchoice_1_158_0'>\n\t\t\t\t<input name='input_158' type='radio' value='Yes'  id='choice_1_158_0'    \/>\n\t\t\t\t<label for='choice_1_158_0' id='label_1_158_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_158_1'>\n\t\t\t\t<input name='input_158' type='radio' value='No'  id='choice_1_158_1'    \/>\n\t\t\t\t<label for='choice_1_158_1' id='label_1_158_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_159\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_159'>Details<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_159' id='input_1_159' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_160\" class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_160'>Number of births you have had<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_160' id='input_1_160' type='text' step='any'   value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_171' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_1_171' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_1_6_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Save and continue later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_6' class='gform_page' data-js='page-field-id-171' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_161\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Antenatal care preference<\/h3>\n<p>Select the <a href=\"https:\/\/metronorth.health.qld.gov.au\/caboolture\/healthcare-services\/maternity-services\/choosing-an-option-for-maternity-care\">maternity care option<\/a> to suit your individual needs.<\/p><\/li><li id=\"field_1_162\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you wish to share care with your GP?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_162'>\n\t\t\t<li class='gchoice gchoice_1_162_0'>\n\t\t\t\t<input name='input_162' type='radio' value='Yes'  id='choice_1_162_0'    \/>\n\t\t\t\t<label for='choice_1_162_0' id='label_1_162_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_162_1'>\n\t\t\t\t<input name='input_162' type='radio' value='No'  id='choice_1_162_1'    \/>\n\t\t\t\t<label for='choice_1_162_1' id='label_1_162_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_162_2'>\n\t\t\t\t<input name='input_162' type='radio' value='Unsure'  id='choice_1_162_2'    \/>\n\t\t\t\t<label for='choice_1_162_2' id='label_1_162_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_163\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Would you be interested in midwifery team care?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_163'>\n\t\t\t<li class='gchoice gchoice_1_163_0'>\n\t\t\t\t<input name='input_163' type='radio' value='Yes'  id='choice_1_163_0'    \/>\n\t\t\t\t<label for='choice_1_163_0' id='label_1_163_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_163_1'>\n\t\t\t\t<input name='input_163' type='radio' value='No'  id='choice_1_163_1'    \/>\n\t\t\t\t<label for='choice_1_163_1' id='label_1_163_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_164\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Please be aware, your medical and obstetric history will determine whether you need to see a doctor on the same day or following your booking in appointment.<\/p>\n<p>Appointments within school hours are extremely popular and can not always be accommodated.<\/p>\n<p>Your partner or a support person, or young children are welcome to attend with you. Please be aware your personal medical and social and history will be discussed and the appointment can take 1-2 hours.<\/p>\n<p>An ultrasound scan does not occur at this visit.<\/p>\n<p>It is important to keep us informed of your current address and telephone numbers. We may need to contact you regarding results or to change an existing appointment. If your contact number changes please call (07) 5433 8701<\/p><\/li><li id=\"field_1_165\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><b>I hereby accept and agree to abide by, the above terms and conditions for submitting this form<font color=\"red\">*<\/font><\/b><\/p><\/li><li id=\"field_1_166\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_166'><li class='gchoice gchoice_1_166_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.1' type='checkbox'  value='I accept and agree'  id='choice_1_166_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_166_1' id='label_1_166_1' class='gform-field-label gform-field-label--type-inline'>I accept and agree<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_192\" class=\"gfield gfield--type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_192'>CAPTCHA<\/label><div id='input_1_192' class='ginput_container ginput_recaptcha' data-sitekey='6LcwcSYUAAAAAFZ0zEoKZIk2yQMA-9rTK4mA5xqZ'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/li><\/ul><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_1' class='gform_previous_button 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