{"id":29377,"date":"2024-09-11T16:17:50","date_gmt":"2024-09-11T13:17:50","guid":{"rendered":"https:\/\/ufukaskeroglu.com\/?page_id=29377"},"modified":"2024-10-09T17:18:20","modified_gmt":"2024-10-09T14:18:20","slug":"medical-history-questionnaire","status":"publish","type":"page","link":"https:\/\/ufukaskeroglu.com\/en\/medical-history-questionnaire\/","title":{"rendered":"Medical History Questionnaire"},"content":{"rendered":"[vc_row type=&#8221;in_container&#8221; full_screen_row_position=&#8221;middle&#8221; column_margin=&#8221;default&#8221; equal_height=&#8221;yes&#8221; content_placement=&#8221;middle&#8221; column_direction=&#8221;default&#8221; column_direction_tablet=&#8221;default&#8221; column_direction_phone=&#8221;default&#8221; full_height=&#8221;yes&#8221; columns_placement=&#8221;stretch&#8221; scene_position=&#8221;center&#8221; text_color=&#8221;dark&#8221; text_align=&#8221;left&#8221; row_border_radius=&#8221;none&#8221; row_border_radius_applies=&#8221;bg&#8221; overflow=&#8221;visible&#8221; overlay_strength=&#8221;0.3&#8243; gradient_direction=&#8221;left_to_right&#8221; shape_divider_position=&#8221;bottom&#8221; bg_image_animation=&#8221;none&#8221; gradient_type=&#8221;default&#8221; shape_type=&#8221;&#8221;][vc_column column_padding=&#8221;no-extra-padding&#8221; column_padding_tablet=&#8221;inherit&#8221; column_padding_phone=&#8221;inherit&#8221; column_padding_position=&#8221;all&#8221; column_element_direction_desktop=&#8221;default&#8221; column_element_spacing=&#8221;default&#8221; desktop_text_alignment=&#8221;default&#8221; tablet_text_alignment=&#8221;default&#8221; phone_text_alignment=&#8221;default&#8221; background_color_opacity=&#8221;1&#8243; background_hover_color_opacity=&#8221;1&#8243; column_backdrop_filter=&#8221;none&#8221; column_shadow=&#8221;none&#8221; column_border_radius=&#8221;none&#8221; column_link_target=&#8221;_self&#8221; column_position=&#8221;default&#8221; gradient_direction=&#8221;left_to_right&#8221; overlay_strength=&#8221;0.3&#8243; width=&#8221;1\/4&#8243; tablet_width_inherit=&#8221;default&#8221; animation_type=&#8221;default&#8221; bg_image_animation=&#8221;none&#8221; border_type=&#8221;simple&#8221; column_border_width=&#8221;none&#8221; column_border_style=&#8221;solid&#8221;][\/vc_column][vc_column column_padding=&#8221;no-extra-padding&#8221; column_padding_tablet=&#8221;inherit&#8221; column_padding_phone=&#8221;inherit&#8221; column_padding_position=&#8221;all&#8221; column_element_direction_desktop=&#8221;default&#8221; column_element_spacing=&#8221;default&#8221; desktop_text_alignment=&#8221;default&#8221; tablet_text_alignment=&#8221;default&#8221; phone_text_alignment=&#8221;default&#8221; background_color_opacity=&#8221;1&#8243; background_hover_color_opacity=&#8221;1&#8243; column_backdrop_filter=&#8221;none&#8221; column_shadow=&#8221;none&#8221; column_border_radius=&#8221;none&#8221; column_link_target=&#8221;_self&#8221; column_position=&#8221;default&#8221; gradient_direction=&#8221;left_to_right&#8221; overlay_strength=&#8221;0.3&#8243; width=&#8221;1\/2&#8243; tablet_width_inherit=&#8221;default&#8221; animation_type=&#8221;default&#8221; bg_image_animation=&#8221;none&#8221; border_type=&#8221;simple&#8221; column_border_width=&#8221;none&#8221; column_border_style=&#8221;solid&#8221;]\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f29376-o1\" lang=\"tr-TR\" dir=\"ltr\" data-wpcf7-id=\"29376\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/29377#wpcf7-f29376-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"\u0130leti\u015fim Formu\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"29376\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.6\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"tr_TR\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f29376-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<h4>Medical History Questionnaire\n<\/h4>\n<div>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" autocomplete=\"name\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Full Name\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span>\n\t<\/p>\n<\/div>\n<div>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"date-900\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Date of Birth\" value=\"\" type=\"date\" name=\"date-900\" \/><\/span>\n\t<\/p>\n<\/div>\n<div>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" autocomplete=\"email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Email Address\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span>\n\t<\/p>\n<\/div>\n<div>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"phonetext-91\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-phonetext wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-phonetext\" autocomplete=\"tel-national\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Contact Number\" value=\"\" type=\"text\" name=\"phonetext-91\" \/><input type=\"hidden\" name=\"phonetext-91-country-code\" class=\"wpcf7-phonetext-country-code\" \/><\/span>\n\t<\/p>\n<\/div>\n<h4>General Health Information:\n<\/h4>\n<p>1) Have you ever been diagnosed with any chronic diseases?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-503\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox-503[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox-503[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><br \/>\nIf yes, please specify:<span class=\"wpcf7-form-control-wrap\" data-name=\"text-312\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-312\" \/><\/span>\n<\/p>\n<p>2) Do you have any known allergies? (e.g., medications, latex, food)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-504\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox-504[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox-504[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><br \/>\nIf yes, please specify:<span class=\"wpcf7-form-control-wrap\" data-name=\"text-313\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-313\" \/><\/span>\n<\/p>\n<p>3) Have you ever been diagnosed with any of the following conditions? (Check all that apply)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-887\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-887[]\" value=\"Diabetes\" \/><span class=\"wpcf7-list-item-label\">Diabetes<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-887[]\" value=\"High Blood Pressure\" \/><span class=\"wpcf7-list-item-label\">High Blood Pressure<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-887[]\" value=\"Heart Disease\" \/><span class=\"wpcf7-list-item-label\">Heart Disease<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-887[]\" value=\"Lung Disease (e.g., Asthma, COPD)\" \/><span class=\"wpcf7-list-item-label\">Lung Disease (e.g., Asthma, COPD)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-887[]\" value=\"Kidney Disease\" \/><span class=\"wpcf7-list-item-label\">Kidney Disease<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-887[]\" value=\"Liver Disease\" \/><span class=\"wpcf7-list-item-label\">Liver Disease<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-887[]\" value=\"Autoimmune Disorder\" \/><span class=\"wpcf7-list-item-label\">Autoimmune Disorder<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-887[]\" value=\"Neurological Disorders (e.g., Epilepsy, Parkinson&#039;s)\" \/><span class=\"wpcf7-list-item-label\">Neurological Disorders (e.g., Epilepsy, Parkinson&#039;s)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-887[]\" value=\"Mental Health Conditions (e.g., Depression, Anxiety)\" \/><span class=\"wpcf7-list-item-label\">Mental Health Conditions (e.g., Depression, Anxiety)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-887[]\" value=\"None of the above\" \/><span class=\"wpcf7-list-item-label\">None of the above<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p>4) Do you have or have you ever had any of the following infectious diseases? (Check all that apply)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-875\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-875[]\" value=\"HIV\/AIDS\" \/><span class=\"wpcf7-list-item-label\">HIV\/AIDS<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-875[]\" value=\"Hepatitis B or C\" \/><span class=\"wpcf7-list-item-label\">Hepatitis B or C<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-875[]\" value=\"Tuberculosis (TB)\" \/><span class=\"wpcf7-list-item-label\">Tuberculosis (TB)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-875[]\" value=\"Herpes Simplex Virus (HSV)\" \/><span class=\"wpcf7-list-item-label\">Herpes Simplex Virus (HSV)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-875[]\" value=\"COVID-19\" \/><span class=\"wpcf7-list-item-label\">COVID-19<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-875[]\" value=\"None of the above\" \/><span class=\"wpcf7-list-item-label\">None of the above<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p>5) Have you had any previous surgeries?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-505\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox-505[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox-505[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><br \/>\nIf yes, please specify:<span class=\"wpcf7-form-control-wrap\" data-name=\"text-314\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-314\" \/><\/span>\n<\/p>\n<p>6) Are you currently taking any medications (including vitamins or supplements)?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-506\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox-506[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox-506[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><br \/>\nIf yes, please specify:<span class=\"wpcf7-form-control-wrap\" data-name=\"text-315\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-315\" \/><\/span>\n<\/p>\n<p>7) Do you smoke or use tobacco products?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-507\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox-507[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox-507[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><br \/>\nIf yes, please specify:<span class=\"wpcf7-form-control-wrap\" data-name=\"text-316\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-316\" \/><\/span>\n<\/p>\n<p>8) Do you consume alcohol?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-508\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox-508[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox-508[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><br \/>\nIf yes, please specify:<span class=\"wpcf7-form-control-wrap\" data-name=\"text-317\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-317\" \/><\/span>\n<\/p>\n<p>9) Do you use any recreational drugs?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-509\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox-509[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox-509[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><br \/>\nIf yes, please specify:<span class=\"wpcf7-form-control-wrap\" data-name=\"text-318\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-318\" \/><\/span>\n<\/p>\n<h4>Medical Risks and Complications:\n<\/h4>\n<p>1) Do you have a history of blood clotting disorders (e.g., Deep Vein Thrombosis, Pulmonary Embolism)?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-510\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox-510[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox-510[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><br \/>\nIf yes, please specify:<span class=\"wpcf7-form-control-wrap\" data-name=\"text-319\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-319\" \/><\/span>\n<\/p>\n<p>2) Have you experienced any complications with anesthesia during previous surgeries?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-511\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox-511[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox-511[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><br \/>\nIf yes, please specify:<span class=\"wpcf7-form-control-wrap\" data-name=\"text-320\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-320\" \/><\/span>\n<\/p>\n<p>3) Do you have any known immune deficiencies or conditions that affect wound healing?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-512\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox-512[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox-512[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><br \/>\nIf yes, please specify:<span class=\"wpcf7-form-control-wrap\" data-name=\"text-321\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-321\" \/><\/span>\n<\/p>\n<p>4) Have you ever received treatment for a serious skin condition (e.g., Eczema, Psoriasis, Keloids)?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-513\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox-513[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox-513[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><br \/>\nIf yes, please specify:<span class=\"wpcf7-form-control-wrap\" data-name=\"text-322\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-322\" \/><\/span>\n<\/p>\n<h4>Female Patients Only:\n<\/h4>\n<p>1) Are you currently pregnant or trying to become pregnant?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-514\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox-514[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox-514[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><br \/>\nIf yes, please specify:<span class=\"wpcf7-form-control-wrap\" data-name=\"text-323\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-323\" \/><\/span>\n<\/p>\n<p>2) Are you currently breastfeeding?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-515\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox-515[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox-515[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><br \/>\nIf yes, please specify:<span class=\"wpcf7-form-control-wrap\" data-name=\"text-324\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-324\" \/><\/span>\n<\/p>\n<p>3) Do you have a history of breast surgeries (for patients considering breast procedures)?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-516\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox-516[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox-516[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><br \/>\nIf yes, please specify:<span class=\"wpcf7-form-control-wrap\" data-name=\"text-325\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-325\" \/><\/span>\n<\/p>\n<p>Consent:<br \/>\nBy signing below, I acknowledge that the information provided is accurate and complete to the best of my knowledge. 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