{"id":22,"date":"2015-10-22T09:30:45","date_gmt":"2015-10-22T07:30:45","guid":{"rendered":"http:\/\/www.shc-swiss.nl\/?page_id=22"},"modified":"2015-11-18T15:50:27","modified_gmt":"2015-11-18T14:50:27","slug":"formulier","status":"publish","type":"page","link":"https:\/\/www.shc-swiss.nl\/de\/formulier\/","title":{"rendered":"HCK\u00ae Microvoedingsstoffen op maat recept."},"content":{"rendered":"<section class=\"wpb-content-wrapper\">[vc_row][vc_column][vc_custom_heading text=&#8221;Voldoende en in een uitgebalanceerde dosering microvoedingsstoffen zijn essentieel voor een gezond en vitaal lichaam. Graag stellen wij geheel vrijblijvend een speciaal op uw behoefte afgestemd recept samen van HCK\u00ae microvoedingsstoffen. &#8221; font_container=&#8221;tag:span|font_size:18|text_align:left|color:%23014991&#8243; google_fonts=&#8221;font_family:Oxygen%3A300%2Cregular%2C700|font_style:700%20bold%20regular%3A700%3Anormal&#8221;][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text]U dient hiervoor circa 10 minuten de tijd te nemen en het uitgebreide vragenformulier volledig en correct in te vullen.\u00a0U ontvangt dan binnen enkele dagen het geheel ge\u00efndividualiseerde recept vrijblijvend per mail.<\/p>\n<p>Het recept wordt samengesteld door onze Apotheke Richter in Zwitserland waarbij gebruik wordt gemaakt van een omvangrijke database met van data.<\/p>\n<p>Indien u een nog meer in detail afgestemd recept wilt dan vragen wij u vriendelijk een afspraak te maken met een van onze SalusMed specialisten. U vindt een lijst met specialisten op de website van <a href=\"http:\/\/www.salusmed.nl\/de-mensen\/\" target=\"_blank\">SalusMed<\/a>.<\/p>\n<p>Mocht u het speciaal voor u, vrijblijvend, samengestelde recept willen gaan gebruiken dan kunt u dat bestellen door een mail te sturen aan info@shc-swiss.nl onder vermelding van het receptnummer.<\/p>\n<p>Na ontvangst van uw mail ontvangt u de factuur. Na betaling daarvan wordt het recept voor u bereid en direct vanuit Zwitserland naar u toegestuurd. Dit duurt circa 1-2 weken.<\/p>\n<p>Heeft u vragen of wilt u meer informatie neem dan contact met ons op.<\/p>\n<p>Bestellen van de op maat samengestelde recepten kan ook telefonisch;<\/p>\n<p>Nederland : 040-3041536<br \/>\nZwitserland : 0041 (0)71 666 83 40[\/vc_column_text][\/vc_column][\/vc_row][vc_row full_width=&#8221;stretch_row&#8221; css=&#8221;.vc_custom_1447845447419{background-color: #f7f7f7 !important;}&#8221;][vc_column][vc_column_text]\n<h3>Aanvraagformulier voedingsstoffen op maat<\/h3>\n[\/vc_column_text]<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\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='\/de\/wp-json\/wp\/v2\/pages\/22#gf_1' data-formid='1' >\n                        <div class='gform-body gform_body'><div id='gform_page_1_1' class='gform_page ' data-js='page-field-id-61' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_1_12\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_12\"><h1><strong>Persoonlijke gegevens<\/strong><\/h1><\/li><li id=\"field_1_1\"  class=\"gfield gfield--type-radio gfield--type-choice label-side gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_1\"><label class='gfield_label gform-field-label'  >Geslacht:<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_1'>\n\t\t\t<li class='gchoice gchoice_1_1_0'>\n\t\t\t\t<input name='input_1' type='radio' value='Vrouw'  id='choice_1_1_0'    \/>\n\t\t\t\t<label for='choice_1_1_0' id='label_1_1_0' class='gform-field-label gform-field-label--type-inline'>Vrouw<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_1_1'>\n\t\t\t\t<input name='input_1' type='radio' value='Man'  id='choice_1_1_1'    \/>\n\t\t\t\t<label for='choice_1_1_1' id='label_1_1_1' class='gform-field-label gform-field-label--type-inline'>Man<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_2\"  class=\"gfield gfield--type-text label-side gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_2\"><label class='gfield_label gform-field-label' for='input_1_2' >Voor- \/ achternaam:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_1_2' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_3\"  class=\"gfield gfield--type-text label-side gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_3\"><label class='gfield_label gform-field-label' for='input_1_3' >Straat \/ nummer:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_1_3' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_4\"  class=\"gfield gfield--type-text label-side gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_4\"><label class='gfield_label gform-field-label' for='input_1_4' >Postcode \/ Woonplaats:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_1_4' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_5\"  class=\"gfield gfield--type-text label-side gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_5\"><label class='gfield_label gform-field-label' for='input_1_5' >Land:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_1_5' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_6\"  class=\"gfield gfield--type-text label-side gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_6\"><label class='gfield_label gform-field-label' for='input_1_6' >Telefoonnummer:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_1_6' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_7\"  class=\"gfield gfield--type-text label-side gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_7\"><label class='gfield_label gform-field-label' for='input_1_7' >E-mail:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_1_7' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_8\"  class=\"gfield gfield--type-text label-side gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_8\"><label class='gfield_label gform-field-label' for='input_1_8' >Geboortedatum (bv 22.07.1965):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_1_8' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_9\"  class=\"gfield gfield--type-text label-side gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_9\"><label class='gfield_label gform-field-label' for='input_1_9' >Gewicht (in kg):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_1_9' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_10\"  class=\"gfield gfield--type-text label-side gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_10\"><label class='gfield_label gform-field-label' for='input_1_10' >Grootte (in cm):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_1_10' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_11\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_11\">[vc_row][vc_column][vc_column_text css=\".vc_custom_1445518751562{background-color: #1e73be !important;}\"]\n<h2 class=\"p1\">Privacy<\/h2>\n\nUw persoonlijke gegevens uit dit formulier worden met inachtname van de geldende regels voor privacy vertrouwelijk behandeld en niet doorgegeven aan derden. De gegevens worden uitsluitend voor deze rapportage elektronisch opgeslagen. Voor statistische (interne) analysen worden alle gegevens geanonimiseerd, waarbij terug herleiden naar individuele personen niet mogelijk is. Van toepassing zijn de algemene voorwaarden versie av 1.2 zoals vermeld op onze internetsite: www.salusmed.nl.\n<p>\n<\/p><\/li><li id=\"field_1_61\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_61\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Accoordverklaring<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_61'><li class='gchoice gchoice_1_61_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.1' type='checkbox'  value='Ik ga hierbij akkoord met de algemene voorwaarden en de opslag van mijn gegevens:'  id='choice_1_61_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_61_1' id='label_1_61_1' class='gform-field-label gform-field-label--type-inline'>Ik ga hierbij akkoord met de algemene voorwaarden en de opslag van mijn gegevens:<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_1_58' class='gform_next_button gform-theme-button button' value='Volgende'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_2' class='gform_page' data-js='page-field-id-58' 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'><li id=\"field_1_14\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_14\"><h1>Activiteit<\/h1><\/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 gfield_visibility_visible\"  data-js-reload=\"field_1_15\"><label class='gfield_label gform-field-label'  >Hoe is uw beroepssituatie het beste te omschrijven:<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='Uitsluitend zittende of liggende levenswijze (bijvoorbeeld: oude of zieke mensen)'  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'>Uitsluitend zittende of liggende levenswijze (bijvoorbeeld: oude of zieke mensen)<\/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='Uitsluitend zittend werk met weinig of geen inspannende afwisseling (bijvoorbeeld: kantoormedewerker, machine-operator, computerwerkzaamheden)'  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'>Uitsluitend zittend werk met weinig of geen inspannende afwisseling (bijvoorbeeld: kantoormedewerker, machine-operator, computerwerkzaamheden)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_15_2'>\n\t\t\t\t<input name='input_15' type='radio' value='Zittende activiteit, deels ook extra inspanning door lopen of anderszins bewegen. (bijvoorbeeld: laborant, student, chauffeur, manager)'  id='choice_1_15_2'    \/>\n\t\t\t\t<label for='choice_1_15_2' id='label_1_15_2' class='gform-field-label gform-field-label--type-inline'>Zittende activiteit, deels ook extra inspanning door lopen of anderszins bewegen. (bijvoorbeeld: laborant, student, chauffeur, manager)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_15_3'>\n\t\t\t\t<input name='input_15' type='radio' value='Overwegend beweging tijdens het werk (bijvoorbeeld: huisvrouw, verkoper, ober, politieagent)'  id='choice_1_15_3'    \/>\n\t\t\t\t<label for='choice_1_15_3' id='label_1_15_3' class='gform-field-label gform-field-label--type-inline'>Overwegend beweging tijdens het werk (bijvoorbeeld: huisvrouw, verkoper, ober, politieagent)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_15_4'>\n\t\t\t\t<input name='input_15' type='radio' value='Fysiek zwaar werk (bijvoorbeeld: bouwvakker, topsporter, hovenier)'  id='choice_1_15_4'    \/>\n\t\t\t\t<label for='choice_1_15_4' id='label_1_15_4' class='gform-field-label gform-field-label--type-inline'>Fysiek zwaar werk (bijvoorbeeld: bouwvakker, topsporter, hovenier)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_16\"  class=\"gfield gfield--type-radio gfield--type-choice gf_list_3col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_16\"><label class='gfield_label gform-field-label'  >Hoe vaak in de week sport u of bezigt u andere inspannende lichamelijke activiteit? (meer dan 30 minuten)<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_16'>\n\t\t\t<li class='gchoice gchoice_1_16_0'>\n\t\t\t\t<input name='input_16' type='radio' value='Nooit'  id='choice_1_16_0'    \/>\n\t\t\t\t<label for='choice_1_16_0' id='label_1_16_0' class='gform-field-label gform-field-label--type-inline'>Nooit<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_16_1'>\n\t\t\t\t<input name='input_16' type='radio' value='1-3 keer'  id='choice_1_16_1'    \/>\n\t\t\t\t<label for='choice_1_16_1' id='label_1_16_1' class='gform-field-label gform-field-label--type-inline'>1-3 keer<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_16_2'>\n\t\t\t\t<input name='input_16' type='radio' value='4 keer of vaker'  id='choice_1_16_2'    \/>\n\t\t\t\t<label for='choice_1_16_2' id='label_1_16_2' class='gform-field-label gform-field-label--type-inline'>4 keer of vaker<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_17\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_17\"><p>\n<\/p>\n<p>\n<\/p>\n<h1>Eetgewoonten<\/h1><\/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_below gfield_visibility_visible\"  data-js-reload=\"field_1_18\"><label class='gfield_label gform-field-label'  >Hoe vaak eet u vlees?<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='nooit'  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'>nooit<\/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='zelden'  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'>zelden<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_18_2'>\n\t\t\t\t<input name='input_18' type='radio' value='regelmatig'  id='choice_1_18_2'    \/>\n\t\t\t\t<label for='choice_1_18_2' id='label_1_18_2' class='gform-field-label gform-field-label--type-inline'>regelmatig<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_18_3'>\n\t\t\t\t<input name='input_18' type='radio' value='dagelijks'  id='choice_1_18_3'    \/>\n\t\t\t\t<label for='choice_1_18_3' id='label_1_18_3' class='gform-field-label gform-field-label--type-inline'>dagelijks<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_18_4'>\n\t\t\t\t<input name='input_18' type='radio' value='dagelijks veel'  id='choice_1_18_4'    \/>\n\t\t\t\t<label for='choice_1_18_4' id='label_1_18_4' class='gform-field-label gform-field-label--type-inline'>dagelijks veel<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_18_5'>\n\t\t\t\t<input name='input_18' type='radio' value='zeer veel'  id='choice_1_18_5'    \/>\n\t\t\t\t<label for='choice_1_18_5' id='label_1_18_5' class='gform-field-label gform-field-label--type-inline'>zeer veel<\/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 gfield_visibility_visible\"  data-js-reload=\"field_1_19\"><label class='gfield_label gform-field-label'  >Hoe vaak eet u vis?<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='nooit'  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'>nooit<\/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='zelden'  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'>zelden<\/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='regelmatig'  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'>regelmatig<\/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='dagelijks'  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'>dagelijks<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_19_4'>\n\t\t\t\t<input name='input_19' type='radio' value='dagelijks veel'  id='choice_1_19_4'    \/>\n\t\t\t\t<label for='choice_1_19_4' id='label_1_19_4' class='gform-field-label gform-field-label--type-inline'>dagelijks veel<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_19_5'>\n\t\t\t\t<input name='input_19' type='radio' value='zeer veel'  id='choice_1_19_5'    \/>\n\t\t\t\t<label for='choice_1_19_5' id='label_1_19_5' class='gform-field-label gform-field-label--type-inline'>zeer veel<\/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 gfield_visibility_visible\"  data-js-reload=\"field_1_20\"><label class='gfield_label gform-field-label'  >Hoe vaak eet u eieren?<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='nooit'  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'>nooit<\/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='zelden'  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'>zelden<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_20_2'>\n\t\t\t\t<input name='input_20' type='radio' value='regelmatig'  id='choice_1_20_2'    \/>\n\t\t\t\t<label for='choice_1_20_2' id='label_1_20_2' class='gform-field-label gform-field-label--type-inline'>regelmatig<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_20_3'>\n\t\t\t\t<input name='input_20' type='radio' value='dagelijks'  id='choice_1_20_3'    \/>\n\t\t\t\t<label for='choice_1_20_3' id='label_1_20_3' class='gform-field-label gform-field-label--type-inline'>dagelijks<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_20_4'>\n\t\t\t\t<input name='input_20' type='radio' value='dagelijks veel'  id='choice_1_20_4'    \/>\n\t\t\t\t<label for='choice_1_20_4' id='label_1_20_4' class='gform-field-label gform-field-label--type-inline'>dagelijks veel<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_20_5'>\n\t\t\t\t<input name='input_20' type='radio' value='zeer veel'  id='choice_1_20_5'    \/>\n\t\t\t\t<label for='choice_1_20_5' id='label_1_20_5' class='gform-field-label gform-field-label--type-inline'>zeer veel<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_21\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_21\"><label class='gfield_label gform-field-label'  >Hoe vaak gebruikt u melkproducten?<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_21'>\n\t\t\t<li class='gchoice gchoice_1_21_0'>\n\t\t\t\t<input name='input_21' type='radio' value='nooit'  id='choice_1_21_0'    \/>\n\t\t\t\t<label for='choice_1_21_0' id='label_1_21_0' class='gform-field-label gform-field-label--type-inline'>nooit<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_21_1'>\n\t\t\t\t<input name='input_21' type='radio' value='zelden'  id='choice_1_21_1'    \/>\n\t\t\t\t<label for='choice_1_21_1' id='label_1_21_1' class='gform-field-label gform-field-label--type-inline'>zelden<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_21_2'>\n\t\t\t\t<input name='input_21' type='radio' value='regelmatig'  id='choice_1_21_2'    \/>\n\t\t\t\t<label for='choice_1_21_2' id='label_1_21_2' class='gform-field-label gform-field-label--type-inline'>regelmatig<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_21_3'>\n\t\t\t\t<input name='input_21' type='radio' value='dagelijks'  id='choice_1_21_3'    \/>\n\t\t\t\t<label for='choice_1_21_3' id='label_1_21_3' class='gform-field-label gform-field-label--type-inline'>dagelijks<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_21_4'>\n\t\t\t\t<input name='input_21' type='radio' value='dagelijks veel'  id='choice_1_21_4'    \/>\n\t\t\t\t<label for='choice_1_21_4' id='label_1_21_4' class='gform-field-label gform-field-label--type-inline'>dagelijks veel<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_21_5'>\n\t\t\t\t<input name='input_21' type='radio' value='zeer veel'  id='choice_1_21_5'    \/>\n\t\t\t\t<label for='choice_1_21_5' id='label_1_21_5' class='gform-field-label gform-field-label--type-inline'>zeer veel<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_22\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_22\"><label class='gfield_label gform-field-label'  >Hoe vaak eet u fruit, salade of groente?<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_22'>\n\t\t\t<li class='gchoice gchoice_1_22_0'>\n\t\t\t\t<input name='input_22' type='radio' value='nooit'  id='choice_1_22_0'    \/>\n\t\t\t\t<label for='choice_1_22_0' id='label_1_22_0' class='gform-field-label gform-field-label--type-inline'>nooit<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_22_1'>\n\t\t\t\t<input name='input_22' type='radio' value='zelden'  id='choice_1_22_1'    \/>\n\t\t\t\t<label for='choice_1_22_1' id='label_1_22_1' class='gform-field-label gform-field-label--type-inline'>zelden<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_22_2'>\n\t\t\t\t<input name='input_22' type='radio' value='regelmatig'  id='choice_1_22_2'    \/>\n\t\t\t\t<label for='choice_1_22_2' id='label_1_22_2' class='gform-field-label gform-field-label--type-inline'>regelmatig<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_22_3'>\n\t\t\t\t<input name='input_22' type='radio' value='dagelijks'  id='choice_1_22_3'    \/>\n\t\t\t\t<label for='choice_1_22_3' id='label_1_22_3' class='gform-field-label gform-field-label--type-inline'>dagelijks<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_22_4'>\n\t\t\t\t<input name='input_22' type='radio' value='dagelijks veel'  id='choice_1_22_4'    \/>\n\t\t\t\t<label for='choice_1_22_4' id='label_1_22_4' class='gform-field-label gform-field-label--type-inline'>dagelijks veel<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_22_5'>\n\t\t\t\t<input name='input_22' type='radio' value='zeer veel'  id='choice_1_22_5'    \/>\n\t\t\t\t<label for='choice_1_22_5' id='label_1_22_5' class='gform-field-label gform-field-label--type-inline'>zeer veel<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_23\"  class=\"gfield gfield--type-radio gfield--type-choice gf_list_4col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_23\"><label class='gfield_label gform-field-label'  >Hoeveel drinkt u per dag?<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_23'>\n\t\t\t<li class='gchoice gchoice_1_23_0'>\n\t\t\t\t<input name='input_23' type='radio' value='&lt; 1 liter'  id='choice_1_23_0'    \/>\n\t\t\t\t<label for='choice_1_23_0' id='label_1_23_0' class='gform-field-label gform-field-label--type-inline'>&lt; 1 liter<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_23_1'>\n\t\t\t\t<input name='input_23' type='radio' value='1-2 liter'  id='choice_1_23_1'    \/>\n\t\t\t\t<label for='choice_1_23_1' id='label_1_23_1' class='gform-field-label gform-field-label--type-inline'>1-2 liter<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_23_2'>\n\t\t\t\t<input name='input_23' type='radio' value='2-3 liter'  id='choice_1_23_2'    \/>\n\t\t\t\t<label for='choice_1_23_2' id='label_1_23_2' class='gform-field-label gform-field-label--type-inline'>2-3 liter<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_23_3'>\n\t\t\t\t<input name='input_23' type='radio' value='&gt; 3 liter'  id='choice_1_23_3'    \/>\n\t\t\t\t<label for='choice_1_23_3' id='label_1_23_3' class='gform-field-label gform-field-label--type-inline'>&gt; 3 liter<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_24\"  class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_24\"><label class='gfield_label gform-field-label'  >Hoeveel alcohol drinkt u? (glas wijn=0.2 liter; glas bier =0.5 liter)<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_24'>\n\t\t\t<li class='gchoice gchoice_1_24_0'>\n\t\t\t\t<input name='input_24' type='radio' value='Niets'  id='choice_1_24_0'    \/>\n\t\t\t\t<label for='choice_1_24_0' id='label_1_24_0' class='gform-field-label gform-field-label--type-inline'>Niets<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_24_1'>\n\t\t\t\t<input name='input_24' type='radio' value='Zelden'  id='choice_1_24_1'    \/>\n\t\t\t\t<label for='choice_1_24_1' id='label_1_24_1' class='gform-field-label gform-field-label--type-inline'>Zelden<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_24_2'>\n\t\t\t\t<input name='input_24' type='radio' value='Dagelijks 1 glas'  id='choice_1_24_2'    \/>\n\t\t\t\t<label for='choice_1_24_2' id='label_1_24_2' class='gform-field-label gform-field-label--type-inline'>Dagelijks 1 glas<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_24_3'>\n\t\t\t\t<input name='input_24' type='radio' value='&gt;3 glazen\/dag'  id='choice_1_24_3'    \/>\n\t\t\t\t<label for='choice_1_24_3' id='label_1_24_3' class='gform-field-label gform-field-label--type-inline'>&gt;3 glazen\/dag<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_24_4'>\n\t\t\t\t<input name='input_24' type='radio' value='&gt; 1 fles\/ dag'  id='choice_1_24_4'    \/>\n\t\t\t\t<label for='choice_1_24_4' id='label_1_24_4' class='gform-field-label gform-field-label--type-inline'>&gt; 1 fles\/ dag<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_25\"  class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_25\"><label class='gfield_label gform-field-label'  >hoeveel rookt u?<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_25'>\n\t\t\t<li class='gchoice gchoice_1_25_0'>\n\t\t\t\t<input name='input_25' type='radio' value='Niets'  id='choice_1_25_0'    \/>\n\t\t\t\t<label for='choice_1_25_0' id='label_1_25_0' class='gform-field-label gform-field-label--type-inline'>Niets<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_25_1'>\n\t\t\t\t<input name='input_25' type='radio' value='&lt; 10 sigaretten\/dag'  id='choice_1_25_1'    \/>\n\t\t\t\t<label for='choice_1_25_1' id='label_1_25_1' class='gform-field-label gform-field-label--type-inline'>&lt; 10 sigaretten\/dag<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_25_2'>\n\t\t\t\t<input name='input_25' type='radio' value='1 pakje\/dag'  id='choice_1_25_2'    \/>\n\t\t\t\t<label for='choice_1_25_2' id='label_1_25_2' class='gform-field-label gform-field-label--type-inline'>1 pakje\/dag<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_25_3'>\n\t\t\t\t<input name='input_25' type='radio' value='&gt; 1 pakje\/dag'  id='choice_1_25_3'    \/>\n\t\t\t\t<label for='choice_1_25_3' id='label_1_25_3' class='gform-field-label gform-field-label--type-inline'>&gt; 1 pakje\/dag<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_25_4'>\n\t\t\t\t<input name='input_25' type='radio' value='&gt; 2 pakjes\/dag'  id='choice_1_25_4'    \/>\n\t\t\t\t<label for='choice_1_25_4' id='label_1_25_4' class='gform-field-label gform-field-label--type-inline'>&gt; 2 pakjes\/dag<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_26\"  class=\"gfield gfield--type-radio gfield--type-choice gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_26\"><label class='gfield_label gform-field-label'  >Wordt er in uw omgeving gerookt?<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_26'>\n\t\t\t<li class='gchoice gchoice_1_26_0'>\n\t\t\t\t<input name='input_26' type='radio' value='Nee'  id='choice_1_26_0'    \/>\n\t\t\t\t<label for='choice_1_26_0' id='label_1_26_0' class='gform-field-label gform-field-label--type-inline'>Nee<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_26_1'>\n\t\t\t\t<input name='input_26' type='radio' value='Ja'  id='choice_1_26_1'    \/>\n\t\t\t\t<label for='choice_1_26_1' id='label_1_26_1' class='gform-field-label gform-field-label--type-inline'>Ja<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_27\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_3col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_27\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Verdraagt u een van de onderstaande producten niet of slecht? (meerdere keuzes mogelijk)<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_27'><li class='gchoice gchoice_1_27_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.1' type='checkbox'  value='Gluten'  id='choice_1_27_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_27_1' id='label_1_27_1' class='gform-field-label gform-field-label--type-inline'>Gluten<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_27_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.2' type='checkbox'  value='Melk\/Melkproducten'  id='choice_1_27_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_27_2' id='label_1_27_2' class='gform-field-label gform-field-label--type-inline'>Melk\/Melkproducten<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_27_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.3' type='checkbox'  value='Vruchten algemeen'  id='choice_1_27_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_27_3' id='label_1_27_3' class='gform-field-label gform-field-label--type-inline'>Vruchten algemeen<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_27_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.4' type='checkbox'  value='Citrusvruchten'  id='choice_1_27_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_27_4' id='label_1_27_4' class='gform-field-label gform-field-label--type-inline'>Citrusvruchten<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_27_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.5' type='checkbox'  value='Pollen\/Hooikoorts etc.'  id='choice_1_27_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_27_5' id='label_1_27_5' class='gform-field-label gform-field-label--type-inline'>Pollen\/Hooikoorts etc.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_27_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.6' type='checkbox'  value='Zeefruit\/Schaaldieren'  id='choice_1_27_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_27_6' id='label_1_27_6' class='gform-field-label gform-field-label--type-inline'>Zeefruit\/Schaaldieren<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_59' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Vorige'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"1\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"1\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_59' class='gform_next_button gform-theme-button button' value='Volgende'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_3' class='gform_page' data-js='page-field-id-59' 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'><li id=\"field_1_28\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_28\"><h1>Diagnose<\/h1>\n<p style=\"text-align: left;\">Aan de rechterzijde geeft u aan hoe vaak u last heeft van genoemde klachten gedurende de afgelopen 12 maanden              \n<p>\n<\/p>\n    regelmaat\nnooit 1 tot 4(bijna) altijd<\/p><\/li><li id=\"field_1_29\"  class=\"gfield gfield--type-radio gfield--type-choice gf_list_4col label-side odlist gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_29\"><label class='gfield_label gform-field-label'  >Obstipatie (verstopping)<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_29'>\n\t\t\t<li class='gchoice gchoice_1_29_0'>\n\t\t\t\t<input name='input_29' type='radio' value='1'  id='choice_1_29_0'    \/>\n\t\t\t\t<label for='choice_1_29_0' id='label_1_29_0' class='gform-field-label gform-field-label--type-inline'>1<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_29_1'>\n\t\t\t\t<input name='input_29' type='radio' value='2'  id='choice_1_29_1'    \/>\n\t\t\t\t<label for='choice_1_29_1' id='label_1_29_1' class='gform-field-label gform-field-label--type-inline'>2<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_29_2'>\n\t\t\t\t<input name='input_29' type='radio' value='3'  id='choice_1_29_2'    \/>\n\t\t\t\t<label for='choice_1_29_2' id='label_1_29_2' class='gform-field-label gform-field-label--type-inline'>3<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_29_3'>\n\t\t\t\t<input name='input_29' type='radio' value='4'  id='choice_1_29_3'    \/>\n\t\t\t\t<label for='choice_1_29_3' id='label_1_29_3' class='gform-field-label gform-field-label--type-inline'>4<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_30\"  class=\"gfield gfield--type-radio gfield--type-choice gf_list_4col label-side odlist gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_30\"><label class='gfield_label gform-field-label'  >Diarree<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_30'>\n\t\t\t<li class='gchoice gchoice_1_30_0'>\n\t\t\t\t<input name='input_30' type='radio' value='1'  id='choice_1_30_0'    \/>\n\t\t\t\t<label for='choice_1_30_0' id='label_1_30_0' class='gform-field-label gform-field-label--type-inline'>1<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_30_1'>\n\t\t\t\t<input name='input_30' type='radio' value='2'  id='choice_1_30_1'    \/>\n\t\t\t\t<label for='choice_1_30_1' id='label_1_30_1' class='gform-field-label gform-field-label--type-inline'>2<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_30_2'>\n\t\t\t\t<input name='input_30' type='radio' value='3'  id='choice_1_30_2'    \/>\n\t\t\t\t<label for='choice_1_30_2' id='label_1_30_2' class='gform-field-label gform-field-label--type-inline'>3<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_30_3'>\n\t\t\t\t<input name='input_30' type='radio' value='4'  id='choice_1_30_3'    \/>\n\t\t\t\t<label for='choice_1_30_3' id='label_1_30_3' class='gform-field-label gform-field-label--type-inline'>4<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_31\"  class=\"gfield gfield--type-radio gfield--type-choice gf_list_2col label-side2 gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_31\"><label class='gfield_label gform-field-label'  >Bent u in de laatste vijf jaar onder behandeling geweest voor kanker?<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_31'>\n\t\t\t<li class='gchoice gchoice_1_31_0'>\n\t\t\t\t<input name='input_31' type='radio' value='Nee'  id='choice_1_31_0'    \/>\n\t\t\t\t<label for='choice_1_31_0' id='label_1_31_0' class='gform-field-label gform-field-label--type-inline'>Nee<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_31_1'>\n\t\t\t\t<input name='input_31' type='radio' value='Ja'  id='choice_1_31_1'    \/>\n\t\t\t\t<label for='choice_1_31_1' id='label_1_31_1' class='gform-field-label gform-field-label--type-inline'>Ja<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_32\"  class=\"gfield gfield--type-radio gfield--type-choice gf_list_2col label-side2 gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_32\"><label class='gfield_label gform-field-label'  >Kan een versterking van het immuunsysteem negatieve gevolgen hebben? (bijv. bij transplantaties, inname van immuunsuppressiva)<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_32'>\n\t\t\t<li class='gchoice gchoice_1_32_0'>\n\t\t\t\t<input name='input_32' type='radio' value='Nee'  id='choice_1_32_0'    \/>\n\t\t\t\t<label for='choice_1_32_0' id='label_1_32_0' class='gform-field-label gform-field-label--type-inline'>Nee<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_32_1'>\n\t\t\t\t<input name='input_32' type='radio' value='Ja'  id='choice_1_32_1'    \/>\n\t\t\t\t<label for='choice_1_32_1' id='label_1_32_1' class='gform-field-label gform-field-label--type-inline'>Ja<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_33\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_33\"><p>\n<\/p>\n<h1>Ziekten \/ aandoeningen<\/h1><\/li><li id=\"field_1_34\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_2col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_34\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >is \u00e9\u00e9n of meerdere ziekten op u van toepassing? (meerdere keuzes mogelijk)<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_34'><li class='gchoice gchoice_1_34_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.1' type='checkbox'  value='Acne'  id='choice_1_34_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_1' id='label_1_34_1' class='gform-field-label gform-field-label--type-inline'>Acne<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.2' type='checkbox'  value='Alzheimer \/ Dementie'  id='choice_1_34_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_2' id='label_1_34_2' class='gform-field-label gform-field-label--type-inline'>Alzheimer \/ Dementie<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.3' type='checkbox'  value='Arteriosclerose'  id='choice_1_34_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_3' id='label_1_34_3' class='gform-field-label gform-field-label--type-inline'>Arteriosclerose<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.4' type='checkbox'  value='Artrose (slijtage gewrichten)'  id='choice_1_34_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_4' id='label_1_34_4' class='gform-field-label gform-field-label--type-inline'>Artrose (slijtage gewrichten)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.5' type='checkbox'  value='(Bronchiale) Astma'  id='choice_1_34_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_5' id='label_1_34_5' class='gform-field-label gform-field-label--type-inline'>(Bronchiale) Astma<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.6' type='checkbox'  value='Bloedvet-stofwisselingsstoornis'  id='choice_1_34_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_6' id='label_1_34_6' class='gform-field-label gform-field-label--type-inline'>Bloedvet-stofwisselingsstoornis<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.7' type='checkbox'  value='Hypertensie \/ Hoge bloeddruk'  id='choice_1_34_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_7' id='label_1_34_7' class='gform-field-label gform-field-label--type-inline'>Hypertensie \/ Hoge bloeddruk<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.8' type='checkbox'  value='Bronchitis'  id='choice_1_34_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_8' id='label_1_34_8' class='gform-field-label gform-field-label--type-inline'>Bronchitis<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.9' type='checkbox'  value='Burnout-syndroom'  id='choice_1_34_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_9' id='label_1_34_9' class='gform-field-label gform-field-label--type-inline'>Burnout-syndroom<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.11' type='checkbox'  value='Chronische vermoeidheid (CVS)'  id='choice_1_34_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_11' id='label_1_34_11' class='gform-field-label gform-field-label--type-inline'>Chronische vermoeidheid (CVS)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.12' type='checkbox'  value='Darmziekte (Morbus Crohn, Colitis Ulcerosa)'  id='choice_1_34_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_12' id='label_1_34_12' class='gform-field-label gform-field-label--type-inline'>Darmziekte (Morbus Crohn, Colitis Ulcerosa)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.13' type='checkbox'  value='Depressie'  id='choice_1_34_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_13' id='label_1_34_13' class='gform-field-label gform-field-label--type-inline'>Depressie<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.14' type='checkbox'  value='Diabetes mellitus (type 1)'  id='choice_1_34_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_14' id='label_1_34_14' class='gform-field-label gform-field-label--type-inline'>Diabetes mellitus (type 1)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.15' type='checkbox'  value='Diabetes mellitus (type 2)'  id='choice_1_34_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_15' id='label_1_34_15' class='gform-field-label gform-field-label--type-inline'>Diabetes mellitus (type 2)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.16' type='checkbox'  value='Ontstekingsziekte (reuma)'  id='choice_1_34_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_16' id='label_1_34_16' class='gform-field-label gform-field-label--type-inline'>Ontstekingsziekte (reuma)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.17' type='checkbox'  value='Epilepsie'  id='choice_1_34_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_17' id='label_1_34_17' class='gform-field-label gform-field-label--type-inline'>Epilepsie<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.18' type='checkbox'  value='Regelmatige verkoudheid'  id='choice_1_34_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_18' id='label_1_34_18' class='gform-field-label gform-field-label--type-inline'>Regelmatige verkoudheid<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.19' type='checkbox'  value='Fibromyalgie (weefsel-, spierpijn)'  id='choice_1_34_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_19' id='label_1_34_19' class='gform-field-label gform-field-label--type-inline'>Fibromyalgie (weefsel-, spierpijn)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.21' type='checkbox'  value='Gastritis (chronische helicobacter-pylori infectie, maagslijmvliesontsteking)'  id='choice_1_34_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_21' id='label_1_34_21' class='gform-field-label gform-field-label--type-inline'>Gastritis (chronische helicobacter-pylori infectie, maagslijmvliesontsteking)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.22' type='checkbox'  value='Haaruitval, broze nagels'  id='choice_1_34_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_22' id='label_1_34_22' class='gform-field-label gform-field-label--type-inline'>Haaruitval, broze nagels<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.23' type='checkbox'  value='Herpes (lippenherpes, gordelroos)'  id='choice_1_34_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_23' id='label_1_34_23' class='gform-field-label gform-field-label--type-inline'>Herpes (lippenherpes, gordelroos)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.24' type='checkbox'  value='Status na hartinfarct'  id='choice_1_34_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_24' id='label_1_34_24' class='gform-field-label gform-field-label--type-inline'>Status na hartinfarct<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.25' type='checkbox'  value='Zwak hart'  id='choice_1_34_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_25' id='label_1_34_25' class='gform-field-label gform-field-label--type-inline'>Zwak hart<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.26' type='checkbox'  value='Hartritmestoornis'  id='choice_1_34_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_26' id='label_1_34_26' class='gform-field-label gform-field-label--type-inline'>Hartritmestoornis<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.27' type='checkbox'  value='Hyperactiviteit (leer- en concentratiestoornissen, ADHD, hyperkinetisch syndroom)'  id='choice_1_34_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_27' id='label_1_34_27' class='gform-field-label gform-field-label--type-inline'>Hyperactiviteit (leer- en concentratiestoornissen, ADHD, hyperkinetisch syndroom)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.28' type='checkbox'  value='Kanker (acuut, onder behandeling)'  id='choice_1_34_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_28' id='label_1_34_28' class='gform-field-label gform-field-label--type-inline'>Kanker (acuut, onder behandeling)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_29'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.29' type='checkbox'  value='Ouderdoms maculadegeneratie'  id='choice_1_34_29'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_29' id='label_1_34_29' class='gform-field-label gform-field-label--type-inline'>Ouderdoms maculadegeneratie<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_31'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.31' type='checkbox'  value='Migraine'  id='choice_1_34_31'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_31' id='label_1_34_31' class='gform-field-label gform-field-label--type-inline'>Migraine<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_32'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.32' type='checkbox'  value='Multiple sclerose (MS)'  id='choice_1_34_32'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_32' id='label_1_34_32' class='gform-field-label gform-field-label--type-inline'>Multiple sclerose (MS)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_33'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.33' type='checkbox'  value='Neurodermitis'  id='choice_1_34_33'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_33' id='label_1_34_33' class='gform-field-label gform-field-label--type-inline'>Neurodermitis<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_34'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.34' type='checkbox'  value='Chronische nierinsuffici\u00ebntie'  id='choice_1_34_34'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_34' id='label_1_34_34' class='gform-field-label gform-field-label--type-inline'>Chronische nierinsuffici\u00ebntie<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_35'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.35' type='checkbox'  value='Osteoporose'  id='choice_1_34_35'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_35' id='label_1_34_35' class='gform-field-label gform-field-label--type-inline'>Osteoporose<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_36'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.36' type='checkbox'  value='Parodontitis'  id='choice_1_34_36'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_36' id='label_1_34_36' class='gform-field-label gform-field-label--type-inline'>Parodontitis<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_37'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.37' type='checkbox'  value='Parkinson'  id='choice_1_34_37'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_37' id='label_1_34_37' class='gform-field-label gform-field-label--type-inline'>Parkinson<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_38'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.38' type='checkbox'  value='Potentieproblemen (erecti\u00eble disfunctie)'  id='choice_1_34_38'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_38' id='label_1_34_38' class='gform-field-label gform-field-label--type-inline'>Potentieproblemen (erecti\u00eble disfunctie)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_39'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.39' type='checkbox'  value='Psoriasis'  id='choice_1_34_39'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_39' id='label_1_34_39' class='gform-field-label gform-field-label--type-inline'>Psoriasis<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_41'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.41' type='checkbox'  value='Overactieve schildklier'  id='choice_1_34_41'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_41' id='label_1_34_41' class='gform-field-label gform-field-label--type-inline'>Overactieve schildklier<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_42'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.42' type='checkbox'  value='Onderactieve schildklier'  id='choice_1_34_42'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_42' id='label_1_34_42' class='gform-field-label gform-field-label--type-inline'>Onderactieve schildklier<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_43'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.43' type='checkbox'  value='Tinnitus (oorsuizen)'  id='choice_1_34_43'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_43' id='label_1_34_43' class='gform-field-label gform-field-label--type-inline'>Tinnitus (oorsuizen)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_44'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.44' type='checkbox'  value='Coeliakie'  id='choice_1_34_44'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_44' id='label_1_34_44' class='gform-field-label gform-field-label--type-inline'>Coeliakie<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_45'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.45' type='checkbox'  value='Geen'  id='choice_1_34_45'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_45' id='label_1_34_45' class='gform-field-label gform-field-label--type-inline'>Geen<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_46'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.46' type='checkbox'  value='Overige'  id='choice_1_34_46'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_46' id='label_1_34_46' class='gform-field-label gform-field-label--type-inline'>Overige<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_39\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_39\"><label class='gfield_label gform-field-label' for='input_1_39' >Overige ziektes:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_39' id='input_1_39' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_35\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_35\"><p>\n<\/p>\n<h1>Medicijngebruik<\/h1><\/li><li id=\"field_1_36\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_2col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_36\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >S.v.p. aankruisen welke medicijnen u regelmatig inneemt:<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_36'><li class='gchoice gchoice_1_36_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.1' type='checkbox'  value='Lipiden \/ Cholesterol verlagers'  id='choice_1_36_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_36_1' id='label_1_36_1' class='gform-field-label gform-field-label--type-inline'>Lipiden \/ Cholesterol verlagers<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_36_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.2' type='checkbox'  value='Anti-diabetes \/ Insuline'  id='choice_1_36_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_36_2' id='label_1_36_2' class='gform-field-label gform-field-label--type-inline'>Anti-diabetes \/ Insuline<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_36_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.3' type='checkbox'  value='Antihypertensiva (bloeddrukverlagers)'  id='choice_1_36_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_36_3' id='label_1_36_3' class='gform-field-label gform-field-label--type-inline'>Antihypertensiva (bloeddrukverlagers)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_36_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.4' type='checkbox'  value='Diuretica'  id='choice_1_36_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_36_4' id='label_1_36_4' class='gform-field-label gform-field-label--type-inline'>Diuretica<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_36_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.5' type='checkbox'  value='Bloedverdunners'  id='choice_1_36_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_36_5' id='label_1_36_5' class='gform-field-label gform-field-label--type-inline'>Bloedverdunners<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_36_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.6' type='checkbox'  value='Hormonen'  id='choice_1_36_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_36_6' id='label_1_36_6' class='gform-field-label gform-field-label--type-inline'>Hormonen<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_36_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.7' type='checkbox'  value='Antiadiposita (gewichtsafname)'  id='choice_1_36_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_36_7' id='label_1_36_7' class='gform-field-label gform-field-label--type-inline'>Antiadiposita (gewichtsafname)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_36_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.8' type='checkbox'  value='Jicht medicijnen'  id='choice_1_36_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_36_8' id='label_1_36_8' class='gform-field-label gform-field-label--type-inline'>Jicht medicijnen<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_36_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.9' type='checkbox'  value='Antidepressiva'  id='choice_1_36_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_36_9' id='label_1_36_9' class='gform-field-label gform-field-label--type-inline'>Antidepressiva<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_36_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.11' type='checkbox'  value='Parkinson medicijnen'  id='choice_1_36_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_36_11' id='label_1_36_11' class='gform-field-label gform-field-label--type-inline'>Parkinson medicijnen<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_36_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.12' type='checkbox'  value='Geen'  id='choice_1_36_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_36_12' id='label_1_36_12' class='gform-field-label gform-field-label--type-inline'>Geen<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_36_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.13' type='checkbox'  value='Andere medicijnen'  id='choice_1_36_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_36_13' id='label_1_36_13' class='gform-field-label gform-field-label--type-inline'>Andere medicijnen<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_40\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_40\"><label class='gfield_label gform-field-label' for='input_1_40' >Andere Medicijnen:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_40' id='input_1_40' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_41\"  class=\"gfield gfield--type-textarea label-side field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_41\"><label class='gfield_label gform-field-label' for='input_1_41' >Preparaten microvoedingsstoffen: (vitamines, mineralen, e.d.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_41' id='input_1_41' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_42\"  class=\"gfield gfield--type-textarea label-side field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_42\"><label class='gfield_label gform-field-label' for='input_1_42' >Overige medicamenten:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_42' id='input_1_42' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_60' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Vorige'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_60' class='gform_next_button gform-theme-button button' value='Volgende'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"4\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"4\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_4' class='gform_page' data-js='page-field-id-60' 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'><li id=\"field_1_43\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_43\"><h1>All\u00e9\u00e9n voor vrouwen (bovenste gedeelte)<\/h1><\/li><li id=\"field_1_44\"  class=\"gfield gfield--type-radio gfield--type-choice label-side gf_list_2col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_44\"><label class='gfield_label gform-field-label'  >Heeft u menstruatieklachten?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_44'>\n\t\t\t<li class='gchoice gchoice_1_44_0'>\n\t\t\t\t<input name='input_44' type='radio' value='Nee'  id='choice_1_44_0'    \/>\n\t\t\t\t<label for='choice_1_44_0' id='label_1_44_0' class='gform-field-label gform-field-label--type-inline'>Nee<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_44_1'>\n\t\t\t\t<input name='input_44' type='radio' value='Ja'  id='choice_1_44_1'    \/>\n\t\t\t\t<label for='choice_1_44_1' id='label_1_44_1' class='gform-field-label gform-field-label--type-inline'>Ja<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_45\"  class=\"gfield gfield--type-radio gfield--type-choice label-side gf_list_2col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_45\"><label class='gfield_label gform-field-label'  >Heeft u overgangsklachten?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_45'>\n\t\t\t<li class='gchoice gchoice_1_45_0'>\n\t\t\t\t<input name='input_45' type='radio' value='Nee'  id='choice_1_45_0'    \/>\n\t\t\t\t<label for='choice_1_45_0' id='label_1_45_0' class='gform-field-label gform-field-label--type-inline'>Nee<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_45_1'>\n\t\t\t\t<input name='input_45' type='radio' value='Ja'  id='choice_1_45_1'    \/>\n\t\t\t\t<label for='choice_1_45_1' id='label_1_45_1' class='gform-field-label gform-field-label--type-inline'>Ja<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_46\"  class=\"gfield gfield--type-radio gfield--type-choice label-side gf_list_2col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_46\"><label class='gfield_label gform-field-label'  >Heeft u libidoproblemen?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_46'>\n\t\t\t<li class='gchoice gchoice_1_46_0'>\n\t\t\t\t<input name='input_46' type='radio' value='Nee'  id='choice_1_46_0'    \/>\n\t\t\t\t<label for='choice_1_46_0' id='label_1_46_0' class='gform-field-label gform-field-label--type-inline'>Nee<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_46_1'>\n\t\t\t\t<input name='input_46' type='radio' value='Ja'  id='choice_1_46_1'    \/>\n\t\t\t\t<label for='choice_1_46_1' id='label_1_46_1' class='gform-field-label gform-field-label--type-inline'>Ja<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_47\"  class=\"gfield gfield--type-radio gfield--type-choice label-side cyclus-list field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_47\"><label class='gfield_label gform-field-label'  >Cyclusdag<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_47'>\n\t\t\t<li class='gchoice gchoice_1_47_0'>\n\t\t\t\t<input name='input_47' type='radio' value='1e tot 10e dag'  id='choice_1_47_0'    \/>\n\t\t\t\t<label for='choice_1_47_0' id='label_1_47_0' class='gform-field-label gform-field-label--type-inline'>1e tot 10e dag<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_47_1'>\n\t\t\t\t<input name='input_47' type='radio' value='11e tot 17e dag'  id='choice_1_47_1'    \/>\n\t\t\t\t<label for='choice_1_47_1' id='label_1_47_1' class='gform-field-label gform-field-label--type-inline'>11e tot 17e dag<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_47_2'>\n\t\t\t\t<input name='input_47' type='radio' value='18e tot 28e dag'  id='choice_1_47_2'    \/>\n\t\t\t\t<label for='choice_1_47_2' id='label_1_47_2' class='gform-field-label gform-field-label--type-inline'>18e tot 28e dag<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_47_3'>\n\t\t\t\t<input name='input_47' type='radio' value='Geen cyclusdag vanwege hormoontherapie (b.v. pil \/ minipil \/ hormoonpleister \/ spiraal \/ . . . )'  id='choice_1_47_3'    \/>\n\t\t\t\t<label for='choice_1_47_3' id='label_1_47_3' class='gform-field-label gform-field-label--type-inline'>Geen cyclusdag vanwege hormoontherapie (b.v. pil \/ minipil \/ hormoonpleister \/ spiraal \/ . . . )<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_47_4'>\n\t\t\t\t<input name='input_47' type='radio' value='Geen cyclusdag vanwege zwangerschap'  id='choice_1_47_4'    \/>\n\t\t\t\t<label for='choice_1_47_4' id='label_1_47_4' class='gform-field-label gform-field-label--type-inline'>Geen cyclusdag vanwege zwangerschap<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_47_5'>\n\t\t\t\t<input name='input_47' type='radio' value='Geen cyclusdag vanwege borstvoeding'  id='choice_1_47_5'    \/>\n\t\t\t\t<label for='choice_1_47_5' id='label_1_47_5' class='gform-field-label gform-field-label--type-inline'>Geen cyclusdag vanwege borstvoeding<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_47_6'>\n\t\t\t\t<input name='input_47' type='radio' value='Geen cyclusdag vanwege overgang (menopauze)'  id='choice_1_47_6'    \/>\n\t\t\t\t<label for='choice_1_47_6' id='label_1_47_6' class='gform-field-label gform-field-label--type-inline'>Geen cyclusdag vanwege overgang (menopauze)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_47_7'>\n\t\t\t\t<input name='input_47' type='radio' value='Geen cyclusdag vanwege postmenopauze (senium)'  id='choice_1_47_7'    \/>\n\t\t\t\t<label for='choice_1_47_7' id='label_1_47_7' class='gform-field-label gform-field-label--type-inline'>Geen cyclusdag vanwege postmenopauze (senium)<\/label>\n\t\t\t<\/li><\/ul><\/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 gfield_visibility_visible\"  data-js-reload=\"field_1_53\"><p>\n<\/p>\n<h1>Algemeen welbevinden (voor mannen en vrouwen)<\/h1><\/li><li id=\"field_1_48\"  class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_48\"><label class='gfield_label gform-field-label'  >Slaapt u goed?<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_48'>\n\t\t\t<li class='gchoice gchoice_1_48_0'>\n\t\t\t\t<input name='input_48' type='radio' value='(Bijna) nooit'  id='choice_1_48_0'    \/>\n\t\t\t\t<label for='choice_1_48_0' id='label_1_48_0' class='gform-field-label gform-field-label--type-inline'>(Bijna) nooit<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_48_1'>\n\t\t\t\t<input name='input_48' type='radio' value='Zelden'  id='choice_1_48_1'    \/>\n\t\t\t\t<label for='choice_1_48_1' id='label_1_48_1' class='gform-field-label gform-field-label--type-inline'>Zelden<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_48_2'>\n\t\t\t\t<input name='input_48' type='radio' value='Soms'  id='choice_1_48_2'    \/>\n\t\t\t\t<label for='choice_1_48_2' id='label_1_48_2' class='gform-field-label gform-field-label--type-inline'>Soms<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_48_3'>\n\t\t\t\t<input name='input_48' type='radio' value='Regelmatig'  id='choice_1_48_3'    \/>\n\t\t\t\t<label for='choice_1_48_3' id='label_1_48_3' class='gform-field-label gform-field-label--type-inline'>Regelmatig<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_48_4'>\n\t\t\t\t<input name='input_48' type='radio' value='(Bijna) altijd'  id='choice_1_48_4'    \/>\n\t\t\t\t<label for='choice_1_48_4' id='label_1_48_4' class='gform-field-label gform-field-label--type-inline'>(Bijna) altijd<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_49\"  class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_49\"><label class='gfield_label gform-field-label'  >Bent u rustig en ontspannen?<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_49'>\n\t\t\t<li class='gchoice gchoice_1_49_0'>\n\t\t\t\t<input name='input_49' type='radio' value='(Bijna) nooit'  id='choice_1_49_0'    \/>\n\t\t\t\t<label for='choice_1_49_0' id='label_1_49_0' class='gform-field-label gform-field-label--type-inline'>(Bijna) nooit<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_49_1'>\n\t\t\t\t<input name='input_49' type='radio' value='Zelden'  id='choice_1_49_1'    \/>\n\t\t\t\t<label for='choice_1_49_1' id='label_1_49_1' class='gform-field-label gform-field-label--type-inline'>Zelden<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_49_2'>\n\t\t\t\t<input name='input_49' type='radio' value='Soms'  id='choice_1_49_2'    \/>\n\t\t\t\t<label for='choice_1_49_2' id='label_1_49_2' class='gform-field-label gform-field-label--type-inline'>Soms<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_49_3'>\n\t\t\t\t<input name='input_49' type='radio' value='Regelmatig'  id='choice_1_49_3'    \/>\n\t\t\t\t<label for='choice_1_49_3' id='label_1_49_3' class='gform-field-label gform-field-label--type-inline'>Regelmatig<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_49_4'>\n\t\t\t\t<input name='input_49' type='radio' value='(Bijna) altijd'  id='choice_1_49_4'    \/>\n\t\t\t\t<label for='choice_1_49_4' id='label_1_49_4' class='gform-field-label gform-field-label--type-inline'>(Bijna) altijd<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_50\"  class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_50\"><label class='gfield_label gform-field-label'  >Heeft u een goed humeur?<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_50'>\n\t\t\t<li class='gchoice gchoice_1_50_0'>\n\t\t\t\t<input name='input_50' type='radio' value='(Bijna) nooit'  id='choice_1_50_0'    \/>\n\t\t\t\t<label for='choice_1_50_0' id='label_1_50_0' class='gform-field-label gform-field-label--type-inline'>(Bijna) nooit<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_50_1'>\n\t\t\t\t<input name='input_50' type='radio' value='Zelden'  id='choice_1_50_1'    \/>\n\t\t\t\t<label for='choice_1_50_1' id='label_1_50_1' class='gform-field-label gform-field-label--type-inline'>Zelden<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_50_2'>\n\t\t\t\t<input name='input_50' type='radio' value='Soms'  id='choice_1_50_2'    \/>\n\t\t\t\t<label for='choice_1_50_2' id='label_1_50_2' class='gform-field-label gform-field-label--type-inline'>Soms<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_50_3'>\n\t\t\t\t<input name='input_50' type='radio' value='Regelmatig'  id='choice_1_50_3'    \/>\n\t\t\t\t<label for='choice_1_50_3' id='label_1_50_3' class='gform-field-label gform-field-label--type-inline'>Regelmatig<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_50_4'>\n\t\t\t\t<input name='input_50' type='radio' value='(Bijna) altijd'  id='choice_1_50_4'    \/>\n\t\t\t\t<label for='choice_1_50_4' id='label_1_50_4' class='gform-field-label gform-field-label--type-inline'>(Bijna) altijd<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_51\"  class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_51\"><label class='gfield_label gform-field-label'  >Heeft u veel energie?<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_51'>\n\t\t\t<li class='gchoice gchoice_1_51_0'>\n\t\t\t\t<input name='input_51' type='radio' value='(Bijna) nooit'  id='choice_1_51_0'    \/>\n\t\t\t\t<label for='choice_1_51_0' id='label_1_51_0' class='gform-field-label gform-field-label--type-inline'>(Bijna) nooit<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_51_1'>\n\t\t\t\t<input name='input_51' type='radio' value='Zelden'  id='choice_1_51_1'    \/>\n\t\t\t\t<label for='choice_1_51_1' id='label_1_51_1' class='gform-field-label gform-field-label--type-inline'>Zelden<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_51_2'>\n\t\t\t\t<input name='input_51' type='radio' value='Soms'  id='choice_1_51_2'    \/>\n\t\t\t\t<label for='choice_1_51_2' id='label_1_51_2' class='gform-field-label gform-field-label--type-inline'>Soms<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_51_3'>\n\t\t\t\t<input name='input_51' type='radio' value='Regelmatig'  id='choice_1_51_3'    \/>\n\t\t\t\t<label for='choice_1_51_3' id='label_1_51_3' class='gform-field-label gform-field-label--type-inline'>Regelmatig<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_51_4'>\n\t\t\t\t<input name='input_51' type='radio' value='(Bijna) altijd'  id='choice_1_51_4'    \/>\n\t\t\t\t<label for='choice_1_51_4' id='label_1_51_4' class='gform-field-label gform-field-label--type-inline'>(Bijna) altijd<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_52\"  class=\"gfield gfield--type-radio gfield--type-choice gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_52\"><label class='gfield_label gform-field-label'  >Voelt u zich gestresst?<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_52'>\n\t\t\t<li class='gchoice gchoice_1_52_0'>\n\t\t\t\t<input name='input_52' type='radio' value='(Bijna) nooit'  id='choice_1_52_0'    \/>\n\t\t\t\t<label for='choice_1_52_0' id='label_1_52_0' class='gform-field-label gform-field-label--type-inline'>(Bijna) nooit<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_52_1'>\n\t\t\t\t<input name='input_52' type='radio' value='Zelden'  id='choice_1_52_1'    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