{"id":115,"date":"2017-04-26T13:52:37","date_gmt":"2017-04-26T11:52:37","guid":{"rendered":"http:\/\/flygmedc.rays.se\/?page_id=115"},"modified":"2024-05-14T17:36:04","modified_gmt":"2024-05-14T17:36:04","slug":"form","status":"publish","type":"page","link":"https:\/\/www.flygmedc.se\/da\/form\/","title":{"rendered":"Health declaration"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"115\" class=\"elementor elementor-115\">\n\t\t\t\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-174cecdc elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"174cecdc\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-2b20ff3e\" data-id=\"2b20ff3e\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-382a1f8a elementor-widget elementor-widget-text-editor\" data-id=\"382a1f8a\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.9.0 - 06-12-2022 *\/\n.elementor-widget-text-editor.elementor-drop-cap-view-stacked .elementor-drop-cap{background-color:#818a91;color:#fff}.elementor-widget-text-editor.elementor-drop-cap-view-framed .elementor-drop-cap{color:#818a91;border:3px solid;background-color:transparent}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap{margin-top:8px}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap-letter{width:1em;height:1em}.elementor-widget-text-editor .elementor-drop-cap{float:left;text-align:center;line-height:1;font-size:50px}.elementor-widget-text-editor .elementor-drop-cap-letter{display:inline-block}<\/style>\t\t\t\t<p>Fill in your health declaration with care. Make sure you answer all the questions.<\/p><p>After you clicked the Send button you will recieve a confirmation message next to the button within a few seconds. If you don\u00b4t get at message you proboly havent answered all the questions so please scroll up and check for validation errors.<\/p>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-670c527 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"670c527\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-fe3cab4\" data-id=\"fe3cab4\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-d815784 elementor-button-align-stretch elementor-widget elementor-widget-form\" data-id=\"d815784\" data-element_type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;button_width&quot;:&quot;25&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor-pro - v3.9.0 - 06-12-2022 *\/\n.elementor-button.elementor-hidden,.elementor-hidden{display:none}.e-form__step{width:100%}.e-form__step:not(.elementor-hidden){display:flex;flex-wrap:wrap}.e-form__buttons{flex-wrap:wrap}.e-form__buttons,.e-form__buttons__wrapper{display:flex}.e-form__indicators{display:flex;justify-content:space-between;align-items:center;flex-wrap:nowrap;font-size:13px;margin-bottom:var(--e-form-steps-indicators-spacing)}.e-form__indicators__indicator{display:flex;flex-direction:column;align-items:center;justify-content:center;flex-basis:0;padding:0 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.e-form__indicators__indicator__separator,.e-form__indicators--type-number .e-form__indicators__indicator__separator,.e-form__indicators--type-number_text .e-form__indicators__indicator__separator{margin-top:calc(var(--e-form-steps-indicator-padding, 30px) \/ 2 - var(--e-form-steps-divider-width, 1px) \/ 2)}.elementor-field-type-hidden{display:none}.elementor-field-type-html{display:inline-block}.elementor-login .elementor-lost-password,.elementor-login .elementor-remember-me{font-size:.85em}.elementor-field-type-recaptcha_v3 .elementor-field-label{display:none}.elementor-field-type-recaptcha_v3 .grecaptcha-badge{z-index:1}.elementor-button .elementor-form-spinner{order:3}.elementor-form .elementor-button>span{display:flex;justify-content:center;align-items:center}.elementor-form .elementor-button .elementor-button-text{white-space:normal;flex-grow:0}.elementor-form .elementor-button svg{height:auto}.elementor-form .elementor-button .e-font-icon-svg{height:1em}.elementor-select-wrapper .select-caret-down-wrapper{position:absolute;top:50%;transform:translateY(-50%);inset-inline-end:10px;pointer-events:none;font-size:11px}.elementor-select-wrapper .select-caret-down-wrapper svg{display:unset;width:1em;aspect-ratio:unset;fill:currentColor}.elementor-select-wrapper .select-caret-down-wrapper i{font-size:19px;line-height:2}.elementor-select-wrapper.remove-before:before{content:\"\"!important}<\/style>\t\t<form class=\"elementor-form\" method=\"post\" name=\"New Form\" action=\"\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"115\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"d815784\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"\" \/>\n\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-state elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-state\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t1. State of licence issue\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[state]\" id=\"form-field-state\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"State of licence issue\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-class elementor-col-30 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-class\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t2. Class of medical certificate applied for\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[class]\" id=\"form-field-class\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t<option value=\"Class 1\">Class 1<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Class 2\">Class 2<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"LAPL\">LAPL<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Class 3 (ATC)\">Class 3 (ATC)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cabin Crew\">Cabin Crew<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Other\">Other<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-surname elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-surname\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t3. Surname\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[surname]\" id=\"form-field-surname\" rows=\"1\" placeholder=\"Surname\" required=\"required\" aria-required=\"true\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_c4bc721 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c4bc721\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t4. Previous surname(s)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_c4bc721]\" id=\"form-field-field_c4bc721\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Previous surname(s)\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-Forenames elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-Forenames\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t5. Forenames\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[Forenames]\" id=\"form-field-Forenames\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Forenames\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-dateofbirth elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-dateofbirth\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t6. Date of birth (dd\/mm\/yyyy)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[dateofbirth]\" id=\"form-field-dateofbirth\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" placeholder=\"dd\/mm\/yyyy\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-Sex elementor-col-30 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-Sex\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t7. Sex\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[Sex]\" id=\"form-field-Sex\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t<option value=\"Male\">Male<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Female\">Female<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-birthplace elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-birthplace\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t8. Place and country of birth\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[birthplace]\" id=\"form-field-birthplace\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Place and country of birth\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-Nationality elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-Nationality\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t9. Nationality\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[Nationality]\" id=\"form-field-Nationality\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Nationality\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-address elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-address\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t10. Permanent address<br>&nbsp;&nbsp;&nbsp;Street address\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[address]\" id=\"form-field-address\" rows=\"1\" placeholder=\"Street address\" required=\"required\" aria-required=\"true\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-zip elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-zip\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t&nbsp;&nbsp;&nbsp;Zip\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[zip]\" id=\"form-field-zip\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Nationality\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-City elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-City\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t&nbsp;&nbsp;&nbsp;City\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[City]\" id=\"form-field-City\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"City\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-Country elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-Country\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t&nbsp;&nbsp;&nbsp;Country\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[Country]\" id=\"form-field-Country\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Country\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-tel elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-tel\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t&nbsp;&nbsp;&nbsp;Telephone No\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[tel]\" id=\"form-field-tel\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Telephone No\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Kun tal og telefonkarakterer (#,-,*, o.s.v.) accepteres.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-mobile elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-mobile\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t&nbsp;&nbsp;&nbsp;Mobile No\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[mobile]\" id=\"form-field-mobile\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Mobile No\" required=\"required\" aria-required=\"true\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Kun tal og telefonkarakterer (#,-,*, o.s.v.) accepteres.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-field_ff517a5 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ff517a5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t&nbsp;&nbsp;&nbsp;Email\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[field_ff517a5]\" id=\"form-field-field_ff517a5\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Email\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_f16ab3f elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f16ab3f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t11. Temporary address<br>&nbsp;&nbsp;&nbsp;Street address\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_f16ab3f]\" id=\"form-field-field_f16ab3f\" rows=\"1\" placeholder=\"Street address\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_b4f4875 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b4f4875\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t&nbsp;&nbsp;&nbsp;Zip\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_b4f4875]\" id=\"form-field-field_b4f4875\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Nationality\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_1f57f4b elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1f57f4b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t&nbsp;&nbsp;&nbsp;City\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_1f57f4b]\" id=\"form-field-field_1f57f4b\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"City\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_d35564f elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d35564f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t&nbsp;&nbsp;&nbsp;Country\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_d35564f]\" id=\"form-field-field_d35564f\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Country\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_9a6926a elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9a6926a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t&nbsp;&nbsp;&nbsp;Telephone No\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_9a6926a]\" id=\"form-field-field_9a6926a\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Telephone No\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Kun tal og telefonkarakterer (#,-,*, o.s.v.) accepteres.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-application elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-application\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t12. Application\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Initial\" id=\"form-field-application-0\" name=\"form_fields[application][]\"> <label for=\"form-field-application-0\">Initial<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Revalidation\/Renewal\" id=\"form-field-application-1\" name=\"form_fields[application][]\"> <label for=\"form-field-application-1\">Revalidation\/Renewal<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-occupation elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-occupation\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t15. Occupation (principal)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[occupation]\" id=\"form-field-occupation\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Occupation (principal)\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-Employer elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-Employer\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t16. Employer\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[Employer]\" id=\"form-field-Employer\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Employer\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-date elementor-col-30 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-date\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t17. Last medical examination<br>&nbsp;&nbsp;&nbsp; Date\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[date]\" id=\"form-field-date\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" placeholder=\"Last medical examination date\" required=\"required\" aria-required=\"true\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-lastmedicaldoctor elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-lastmedicaldoctor\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t&nbsp;&nbsp;&nbsp;Doctor and Place\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[lastmedicaldoctor]\" id=\"form-field-lastmedicaldoctor\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Doctor and Place\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-licences elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-licences\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t18. Licence(s) held <br><br>&nbsp;&nbsp;&nbsp;Type\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"APTL\" id=\"form-field-licences-0\" name=\"form_fields[licences][]\"> <label for=\"form-field-licences-0\">APTL<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"CPL\" id=\"form-field-licences-1\" name=\"form_fields[licences][]\"> <label for=\"form-field-licences-1\">CPL<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"CPL-IR\" id=\"form-field-licences-2\" name=\"form_fields[licences][]\"> <label for=\"form-field-licences-2\">CPL-IR<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"PPL-IR\" id=\"form-field-licences-3\" name=\"form_fields[licences][]\"> <label for=\"form-field-licences-3\">PPL-IR<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"PPL\" id=\"form-field-licences-4\" name=\"form_fields[licences][]\"> <label for=\"form-field-licences-4\">PPL<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"ATC\" id=\"form-field-licences-5\" name=\"form_fields[licences][]\"> <label for=\"form-field-licences-5\">ATC<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Cabin Crew\" id=\"form-field-licences-6\" name=\"form_fields[licences][]\"> <label for=\"form-field-licences-6\">Cabin Crew<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Segelflyg\" id=\"form-field-licences-7\" name=\"form_fields[licences][]\"> <label for=\"form-field-licences-7\">Segelflyg<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"UL\" id=\"form-field-licences-8\" name=\"form_fields[licences][]\"> <label for=\"form-field-licences-8\">UL<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Other (please specify below)\" id=\"form-field-licences-9\" name=\"form_fields[licences][]\"> <label for=\"form-field-licences-9\">Other (please specify below)<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_98b3baf elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_98b3baf\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t&nbsp;&nbsp;&nbsp;If other above\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_98b3baf]\" id=\"form-field-field_98b3baf\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_ffea4f7 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ffea4f7\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t&nbsp;&nbsp;&nbsp; License number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_ffea4f7]\" id=\"form-field-field_ffea4f7\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"License number\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_8a35155 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8a35155\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t&nbsp;&nbsp;&nbsp; State of issue\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_8a35155]\" id=\"form-field-field_8a35155\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"State of issue\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_2adada4 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2adada4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t19. Any Limitations on Licence(s)\/Medical Certificate held\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_2adada4-0\" name=\"form_fields[field_2adada4][]\"> <label for=\"form-field-field_2adada4-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_2adada4-1\" name=\"form_fields[field_2adada4][]\"> <label for=\"form-field-field_2adada4-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-Details elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-Details\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t&nbsp;&nbsp;&nbsp; Details\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[Details]\" id=\"form-field-Details\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Details\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_6057a39 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6057a39\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t20. Have you ever had a medical certificate denied, suspended or revoked by any licensing authority?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_6057a39-0\" name=\"form_fields[field_6057a39][]\"> <label for=\"form-field-field_6057a39-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_6057a39-1\" name=\"form_fields[field_6057a39][]\"> <label for=\"form-field-field_6057a39-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_ac7500d elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ac7500d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t&nbsp;&nbsp;&nbsp; Date\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_ac7500d]\" id=\"form-field-field_ac7500d\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" placeholder=\"yyyy-mm-dd\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_ba5e8d6 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ba5e8d6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t&nbsp;&nbsp;&nbsp; Country\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_ba5e8d6]\" id=\"form-field-field_ba5e8d6\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Country\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_90d7591 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_90d7591\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t&nbsp;&nbsp;&nbsp; Details\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_90d7591]\" id=\"form-field-field_90d7591\" rows=\"4\" placeholder=\"Details\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-flighttimetotal elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-flighttimetotal\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t21. Flight time total\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[flighttimetotal]\" id=\"form-field-flighttimetotal\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Flight time total\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a4f024b elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a4f024b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t22. Flight time since last medical\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a4f024b]\" id=\"form-field-field_a4f024b\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Flight time since last medical\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_0764759 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0764759\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t23. Aircraft class\/type(s) presently flown\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Helicopter\" id=\"form-field-field_0764759-0\" name=\"form_fields[field_0764759][]\"> <label for=\"form-field-field_0764759-0\">Helicopter<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"MEP\" id=\"form-field-field_0764759-1\" name=\"form_fields[field_0764759][]\"> <label for=\"form-field-field_0764759-1\">MEP<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"MPA\" id=\"form-field-field_0764759-2\" name=\"form_fields[field_0764759][]\"> <label for=\"form-field-field_0764759-2\">MPA<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"SEP\" id=\"form-field-field_0764759-3\" name=\"form_fields[field_0764759][]\"> <label for=\"form-field-field_0764759-3\">SEP<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"N\/A\" id=\"form-field-field_0764759-4\" name=\"form_fields[field_0764759][]\"> <label for=\"form-field-field_0764759-4\">N\/A<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_4feb81d elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4feb81d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t24. Any aviation accident or reported incident since the last medical examination?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_4feb81d-0\" name=\"form_fields[field_4feb81d][]\"> <label for=\"form-field-field_4feb81d-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_4feb81d-1\" name=\"form_fields[field_4feb81d][]\"> <label for=\"form-field-field_4feb81d-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-date elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-date\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t&nbsp;&nbsp;&nbsp; Date\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[date]\" id=\"form-field-date\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" placeholder=\"yyyy-mm-dd\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_f16becc elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f16becc\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t&nbsp;&nbsp;&nbsp; Place\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_f16becc]\" id=\"form-field-field_f16becc\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Place\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_16f8ac5 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_16f8ac5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t&nbsp;&nbsp;&nbsp; Details\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_16f8ac5]\" id=\"form-field-field_16f8ac5\" rows=\"4\" placeholder=\"Details\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_be8afab elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_be8afab\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t25. Type of flying intended\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_be8afab]\" id=\"form-field-field_be8afab\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Type of flying intended\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_fe19fc5 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_fe19fc5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t26. Present flying activity\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Single pilot\" id=\"form-field-field_fe19fc5-0\" name=\"form_fields[field_fe19fc5][]\"> <label for=\"form-field-field_fe19fc5-0\">Single pilot<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Multipilot\" id=\"form-field-field_fe19fc5-1\" name=\"form_fields[field_fe19fc5][]\"> <label for=\"form-field-field_fe19fc5-1\">Multipilot<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-drinkalcohol elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-drinkalcohol\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t27. Do you drink Alcohol?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-drinkalcohol-0\" name=\"form_fields[drinkalcohol][]\"> <label for=\"form-field-drinkalcohol-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-drinkalcohol-1\" name=\"form_fields[drinkalcohol][]\"> <label for=\"form-field-drinkalcohol-1\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_bef46c7 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_bef46c7\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t&nbsp;&nbsp;&nbsp; Weekly amount\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_bef46c7]\" id=\"form-field-field_bef46c7\" rows=\"1\" placeholder=\"Details\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_3221cd2 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3221cd2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t28. Do you currently use any medication\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_3221cd2-0\" name=\"form_fields[field_3221cd2][]\"> <label for=\"form-field-field_3221cd2-0\">No<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes (Please state below)\" id=\"form-field-field_3221cd2-1\" name=\"form_fields[field_3221cd2][]\"> <label for=\"form-field-field_3221cd2-1\">Yes (Please state below)<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_61f8705 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_61f8705\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t29. Do you smoke tobacco?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No, never\" id=\"form-field-field_61f8705-0\" name=\"form_fields[field_61f8705][]\"> <label for=\"form-field-field_61f8705-0\">No, never<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Not anymore, but smoked before\" id=\"form-field-field_61f8705-1\" name=\"form_fields[field_61f8705][]\"> <label for=\"form-field-field_61f8705-1\">Not anymore, but smoked before<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_61f8705-2\" name=\"form_fields[field_61f8705][]\"> <label for=\"form-field-field_61f8705-2\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_59f5d86 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_59f5d86\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t&nbsp;&nbsp;&nbsp; If you smoked tobacco before and stopped, please state <b> date stopped<\/b> \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_59f5d86]\" id=\"form-field-field_59f5d86\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" placeholder=\"Date\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_597fc0e elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_597fc0e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t&nbsp;&nbsp;&nbsp; If you are smoking tobacco, please <b> state type and amount<\/b> \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_597fc0e]\" id=\"form-field-field_597fc0e\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Tobacco type and amount\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_b4c8c94 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b4c8c94\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t<b>General and medical history: <br>Do you have, or have you ever had, any of the following? YES or NO (or has indicated) must be ticked after each question. Elaborate YES answers in remarks section (30).<\/b><br>101. Eye trouble\/eye operation\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_b4c8c94-0\" name=\"form_fields[field_b4c8c94][]\"> <label for=\"form-field-field_b4c8c94-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_b4c8c94-1\" name=\"form_fields[field_b4c8c94][]\"> <label for=\"form-field-field_b4c8c94-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_11824b1 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_11824b1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t102. Spectacles and\/or contact lenses ever worn\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_11824b1-0\" name=\"form_fields[field_11824b1][]\"> <label for=\"form-field-field_11824b1-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_11824b1-1\" name=\"form_fields[field_11824b1][]\"> <label for=\"form-field-field_11824b1-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_4067b41 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4067b41\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t103. Spectacles\/contact lens precriptions change since last medical exam.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_4067b41-0\" name=\"form_fields[field_4067b41][]\"> <label for=\"form-field-field_4067b41-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_4067b41-1\" name=\"form_fields[field_4067b41][]\"> <label for=\"form-field-field_4067b41-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_a9fb3da elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a9fb3da\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t104. Hay fever, other allergy\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_a9fb3da-0\" name=\"form_fields[field_a9fb3da][]\"> <label for=\"form-field-field_a9fb3da-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_a9fb3da-1\" name=\"form_fields[field_a9fb3da][]\"> <label for=\"form-field-field_a9fb3da-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_e734e6c elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e734e6c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t105. Asthma, lung disease\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_e734e6c-0\" name=\"form_fields[field_e734e6c][]\"> <label for=\"form-field-field_e734e6c-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_e734e6c-1\" name=\"form_fields[field_e734e6c][]\"> <label for=\"form-field-field_e734e6c-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_9ac5d55 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9ac5d55\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t106. Heart or vascular trouble\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_9ac5d55-0\" name=\"form_fields[field_9ac5d55][]\"> <label for=\"form-field-field_9ac5d55-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_9ac5d55-1\" name=\"form_fields[field_9ac5d55][]\"> <label for=\"form-field-field_9ac5d55-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_1c18663 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1c18663\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t107. High or low blood pressure\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_1c18663-0\" name=\"form_fields[field_1c18663][]\"> <label for=\"form-field-field_1c18663-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_1c18663-1\" name=\"form_fields[field_1c18663][]\"> <label for=\"form-field-field_1c18663-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_2a68c46 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2a68c46\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t108. Kidney stone or blood in urine\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_2a68c46-0\" name=\"form_fields[field_2a68c46][]\"> <label for=\"form-field-field_2a68c46-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_2a68c46-1\" name=\"form_fields[field_2a68c46][]\"> <label for=\"form-field-field_2a68c46-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_2923a86 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2923a86\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t109. Diabetes, hormone disorder\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_2923a86-0\" name=\"form_fields[field_2923a86][]\"> <label for=\"form-field-field_2923a86-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_2923a86-1\" name=\"form_fields[field_2923a86][]\"> <label for=\"form-field-field_2923a86-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_3289122 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3289122\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t110. Stomach, liver or intertinal trouble\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_3289122-0\" name=\"form_fields[field_3289122][]\"> <label for=\"form-field-field_3289122-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_3289122-1\" name=\"form_fields[field_3289122][]\"> <label for=\"form-field-field_3289122-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_2c2c3d1 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2c2c3d1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t111. Deafness, ear disorder\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_2c2c3d1-0\" name=\"form_fields[field_2c2c3d1][]\"> <label for=\"form-field-field_2c2c3d1-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_2c2c3d1-1\" name=\"form_fields[field_2c2c3d1][]\"> <label for=\"form-field-field_2c2c3d1-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_0881d48 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0881d48\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t112. Nose, throat or speech disorder\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_0881d48-0\" name=\"form_fields[field_0881d48][]\"> <label for=\"form-field-field_0881d48-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_0881d48-1\" name=\"form_fields[field_0881d48][]\"> <label for=\"form-field-field_0881d48-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_e4185c1 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e4185c1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t113. Head injury or concussion\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_e4185c1-0\" name=\"form_fields[field_e4185c1][]\"> <label for=\"form-field-field_e4185c1-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_e4185c1-1\" name=\"form_fields[field_e4185c1][]\"> <label for=\"form-field-field_e4185c1-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_7a8d081 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7a8d081\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t114. Frequent or severe headaches\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_7a8d081-0\" name=\"form_fields[field_7a8d081][]\"> <label for=\"form-field-field_7a8d081-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_7a8d081-1\" name=\"form_fields[field_7a8d081][]\"> <label for=\"form-field-field_7a8d081-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_786957d elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_786957d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t115. Dixxiness or fanting spells\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_786957d-0\" name=\"form_fields[field_786957d][]\"> <label for=\"form-field-field_786957d-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_786957d-1\" name=\"form_fields[field_786957d][]\"> <label for=\"form-field-field_786957d-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_0a19db7 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0a19db7\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t116. Unconsciouness for any reason\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_0a19db7-0\" name=\"form_fields[field_0a19db7][]\"> <label for=\"form-field-field_0a19db7-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_0a19db7-1\" name=\"form_fields[field_0a19db7][]\"> <label for=\"form-field-field_0a19db7-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_9d8627b elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9d8627b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t117. Neurological disorders: stroke, epilepsy, seizure, paralysis etc\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_9d8627b-0\" name=\"form_fields[field_9d8627b][]\"> <label for=\"form-field-field_9d8627b-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_9d8627b-1\" name=\"form_fields[field_9d8627b][]\"> <label for=\"form-field-field_9d8627b-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_2fcb303 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2fcb303\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t118. Psychological\/psychiatric trouble of any sort\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_2fcb303-0\" name=\"form_fields[field_2fcb303][]\"> <label for=\"form-field-field_2fcb303-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_2fcb303-1\" name=\"form_fields[field_2fcb303][]\"> <label for=\"form-field-field_2fcb303-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_6be6b87 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6be6b87\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t119. Alcohol\/drug\/substance abuse\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_6be6b87-0\" name=\"form_fields[field_6be6b87][]\"> <label for=\"form-field-field_6be6b87-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_6be6b87-1\" name=\"form_fields[field_6be6b87][]\"> <label for=\"form-field-field_6be6b87-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_5c98eff elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5c98eff\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t120. Attempted suicide\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_5c98eff-0\" name=\"form_fields[field_5c98eff][]\"> <label for=\"form-field-field_5c98eff-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_5c98eff-1\" name=\"form_fields[field_5c98eff][]\"> <label for=\"form-field-field_5c98eff-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_0a8ffe8 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0a8ffe8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t121. Motion sickness requiring medication\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_0a8ffe8-0\" name=\"form_fields[field_0a8ffe8][]\"> <label for=\"form-field-field_0a8ffe8-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_0a8ffe8-1\" name=\"form_fields[field_0a8ffe8][]\"> <label for=\"form-field-field_0a8ffe8-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_ae39e1b elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ae39e1b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t122. Anaemia \/ Sickle cell trait \/ other blood disorders\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_ae39e1b-0\" name=\"form_fields[field_ae39e1b][]\"> <label for=\"form-field-field_ae39e1b-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_ae39e1b-1\" name=\"form_fields[field_ae39e1b][]\"> <label for=\"form-field-field_ae39e1b-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_5643345 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5643345\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t123. Malaria or other tropical disease\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_5643345-0\" name=\"form_fields[field_5643345][]\"> <label for=\"form-field-field_5643345-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_5643345-1\" name=\"form_fields[field_5643345][]\"> <label for=\"form-field-field_5643345-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_13acecb elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_13acecb\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t124. A positive HIV test\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_13acecb-0\" name=\"form_fields[field_13acecb][]\"> <label for=\"form-field-field_13acecb-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_13acecb-1\" name=\"form_fields[field_13acecb][]\"> <label for=\"form-field-field_13acecb-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_6e39648 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6e39648\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t125. Sexually transmitted disease\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_6e39648-0\" name=\"form_fields[field_6e39648][]\"> <label for=\"form-field-field_6e39648-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_6e39648-1\" name=\"form_fields[field_6e39648][]\"> <label for=\"form-field-field_6e39648-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_2597b3b elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2597b3b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t126. Sleep disorder\/apnoea syndrome\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_2597b3b-0\" name=\"form_fields[field_2597b3b][]\"> <label for=\"form-field-field_2597b3b-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_2597b3b-1\" name=\"form_fields[field_2597b3b][]\"> <label for=\"form-field-field_2597b3b-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_0cfdfed elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0cfdfed\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t127. Musculoskeletal illness\/impairment\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_0cfdfed-0\" name=\"form_fields[field_0cfdfed][]\"> <label for=\"form-field-field_0cfdfed-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_0cfdfed-1\" name=\"form_fields[field_0cfdfed][]\"> <label for=\"form-field-field_0cfdfed-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_f34780b elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f34780b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t128. Any other illness or injury\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_f34780b-0\" name=\"form_fields[field_f34780b][]\"> <label for=\"form-field-field_f34780b-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_f34780b-1\" name=\"form_fields[field_f34780b][]\"> <label for=\"form-field-field_f34780b-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_9538030 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9538030\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t129. Admission to hospital\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_9538030-0\" name=\"form_fields[field_9538030][]\"> <label for=\"form-field-field_9538030-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_9538030-1\" name=\"form_fields[field_9538030][]\"> <label for=\"form-field-field_9538030-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_3abd7b4 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3abd7b4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t130. Visit to medical practitioner since last medical examination\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_3abd7b4-0\" name=\"form_fields[field_3abd7b4][]\"> <label for=\"form-field-field_3abd7b4-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_3abd7b4-1\" name=\"form_fields[field_3abd7b4][]\"> <label for=\"form-field-field_3abd7b4-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_2b714d1 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2b714d1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t131. Refusal of life insurance\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_2b714d1-0\" name=\"form_fields[field_2b714d1][]\"> <label for=\"form-field-field_2b714d1-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_2b714d1-1\" name=\"form_fields[field_2b714d1][]\"> <label for=\"form-field-field_2b714d1-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_b0c8424 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b0c8424\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t132. Refusal of flying licence\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_b0c8424-0\" name=\"form_fields[field_b0c8424][]\"> <label for=\"form-field-field_b0c8424-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_b0c8424-1\" name=\"form_fields[field_b0c8424][]\"> <label for=\"form-field-field_b0c8424-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_14f4db7 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_14f4db7\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t133. Medical rejection from or for military service\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_14f4db7-0\" name=\"form_fields[field_14f4db7][]\"> <label for=\"form-field-field_14f4db7-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_14f4db7-1\" name=\"form_fields[field_14f4db7][]\"> <label for=\"form-field-field_14f4db7-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_82d5651 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_82d5651\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t134. Award of pension or compensation for injury or illness\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_82d5651-0\" name=\"form_fields[field_82d5651][]\"> <label for=\"form-field-field_82d5651-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_82d5651-1\" name=\"form_fields[field_82d5651][]\"> <label for=\"form-field-field_82d5651-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_2b9ad2b elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2b9ad2b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t<b>Family history of<\/b><br>170. Heart disease\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_2b9ad2b-0\" name=\"form_fields[field_2b9ad2b][]\"> <label for=\"form-field-field_2b9ad2b-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_2b9ad2b-1\" name=\"form_fields[field_2b9ad2b][]\"> <label for=\"form-field-field_2b9ad2b-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_2113796 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2113796\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t171. High blood pressure\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_2113796-0\" name=\"form_fields[field_2113796][]\"> <label for=\"form-field-field_2113796-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_2113796-1\" name=\"form_fields[field_2113796][]\"> <label for=\"form-field-field_2113796-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_5299c49 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5299c49\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t172. High cholesterol level\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_5299c49-0\" name=\"form_fields[field_5299c49][]\"> <label for=\"form-field-field_5299c49-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_5299c49-1\" name=\"form_fields[field_5299c49][]\"> <label for=\"form-field-field_5299c49-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_c5dc55b elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c5dc55b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t173. Epilepsy\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_c5dc55b-0\" name=\"form_fields[field_c5dc55b][]\"> <label for=\"form-field-field_c5dc55b-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_c5dc55b-1\" name=\"form_fields[field_c5dc55b][]\"> <label for=\"form-field-field_c5dc55b-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_da628a6 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_da628a6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t174. Mental illness\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_da628a6-0\" name=\"form_fields[field_da628a6][]\"> <label for=\"form-field-field_da628a6-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_da628a6-1\" name=\"form_fields[field_da628a6][]\"> <label for=\"form-field-field_da628a6-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_c78a79c elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c78a79c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t175. Diabetes\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_c78a79c-0\" name=\"form_fields[field_c78a79c][]\"> <label for=\"form-field-field_c78a79c-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_c78a79c-1\" name=\"form_fields[field_c78a79c][]\"> <label for=\"form-field-field_c78a79c-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_2809fff elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2809fff\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t176. Tuberculosis\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_2809fff-0\" name=\"form_fields[field_2809fff][]\"> <label for=\"form-field-field_2809fff-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_2809fff-1\" name=\"form_fields[field_2809fff][]\"> <label for=\"form-field-field_2809fff-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_08948d8 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_08948d8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t177. Allergy\/asthma\/eczema\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_08948d8-0\" name=\"form_fields[field_08948d8][]\"> <label for=\"form-field-field_08948d8-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_08948d8-1\" name=\"form_fields[field_08948d8][]\"> <label for=\"form-field-field_08948d8-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_dbb9469 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_dbb9469\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t178. Inherited disorders\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_dbb9469-0\" name=\"form_fields[field_dbb9469][]\"> <label for=\"form-field-field_dbb9469-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_dbb9469-1\" name=\"form_fields[field_dbb9469][]\"> <label for=\"form-field-field_dbb9469-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_3b0cfa7 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3b0cfa7\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t<b>Females only<\/b><br>150. Gynaecological, mentrual problems?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_3b0cfa7-0\" name=\"form_fields[field_3b0cfa7][]\"> <label for=\"form-field-field_3b0cfa7-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_3b0cfa7-1\" name=\"form_fields[field_3b0cfa7][]\"> <label for=\"form-field-field_3b0cfa7-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_390a08e elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_390a08e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t151. Are you pregnant?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_390a08e-0\" name=\"form_fields[field_390a08e][]\"> <label for=\"form-field-field_390a08e-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_390a08e-1\" name=\"form_fields[field_390a08e][]\"> <label for=\"form-field-field_390a08e-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_c541dcf elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c541dcf\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t30. Remarks\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_c541dcf]\" id=\"form-field-field_c541dcf\" rows=\"10\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_6fe2d6f elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6fe2d6f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAre there any changes since the last medical check?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_6fe2d6f-0\" name=\"form_fields[field_6fe2d6f][]\"> <label for=\"form-field-field_6fe2d6f-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_6fe2d6f-1\" name=\"form_fields[field_6fe2d6f][]\"> <label for=\"form-field-field_6fe2d6f-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_e4e2e2b elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e4e2e2b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf so, please state the changes\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_e4e2e2b]\" id=\"form-field-field_e4e2e2b\" rows=\"4\" placeholder=\"Changes since last medical check\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-25 e-form__buttons\">\n\t\t\t\t\t<button type=\"submit\" class=\"elementor-button elementor-size-sm\">\n\t\t\t\t\t\t<span >\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Send<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<input type=\"hidden\" name=\"trp-form-language\" value=\"da\"\/><\/form>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-90875d0 elementor-widget elementor-widget-text-editor\" data-id=\"90875d0\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<p>After you clicked the Send button you will recieve a confirmation message next to the button within a few seconds. If you don\u00b4t get at message you proboly havent answered all the questions so please scroll up and check for validation errors.<\/p>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t\t\t<\/div>","protected":false},"excerpt":{"rendered":"<p>Fill in your health declaration with care. Make sure you answer all the questions. After you clicked the Send button you will recieve a confirmation message next to the button within a few seconds. If you don\u00b4t get at message you proboly havent answered all the questions so please scroll up and check for validation [&hellip;]<\/p>","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_mi_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"class_list":["post-115","page","type-page","status-publish","hentry"],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/www.flygmedc.se\/da\/wp-json\/wp\/v2\/pages\/115","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.flygmedc.se\/da\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.flygmedc.se\/da\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.flygmedc.se\/da\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.flygmedc.se\/da\/wp-json\/wp\/v2\/comments?post=115"}],"version-history":[{"count":76,"href":"https:\/\/www.flygmedc.se\/da\/wp-json\/wp\/v2\/pages\/115\/revisions"}],"predecessor-version":[{"id":1541,"href":"https:\/\/www.flygmedc.se\/da\/wp-json\/wp\/v2\/pages\/115\/revisions\/1541"}],"wp:attachment":[{"href":"https:\/\/www.flygmedc.se\/da\/wp-json\/wp\/v2\/media?parent=115"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}