{"id":4280,"date":"2022-11-07T15:23:15","date_gmt":"2022-11-07T20:23:15","guid":{"rendered":"https:\/\/www1.specialolympicsontario.com\/health\/?page_id=4280"},"modified":"2022-11-07T15:23:28","modified_gmt":"2022-11-07T20:23:28","slug":"health-survey-2022","status":"publish","type":"page","link":"https:\/\/www1.specialolympicsontario.com\/health\/health-survey-2022\/","title":{"rendered":"Health Survey 2022"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_35' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Current State of Health Among Persons with Intellectual Disability<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_35'  action='\/health\/wp-json\/wp\/v2\/pages\/4280' data-formid='35' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_35' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_35_1\" class=\"gfield gfield--type-Infobox field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gform_infobox exclude gform_infobox_information\"  data-field-class=\"gform_infobox exclude gform_infobox_information\" ><div class='gfield_label'>Current State of Health Among Persons with Intellectual Disability<\/div><div class='gfield_description'>We would like to know more about your current state of health. This survey will ask you about your health behaviours and desired Special Olympics Healthy Athlete programming.<\/div><\/div><fieldset id=\"field_35_3\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name (Optional)<\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_35_3'>\n                            \n                            <span id='input_35_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_35_3_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_35_3_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_35_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.6' id='input_35_3_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_35_3_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_35_52\" class=\"gfield gfield--type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_52'><span class='gform-field-label__text'>How old are you? (example: if you are 18 years old, write 18)<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_52' id='input_35_52' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_35_61\" class=\"gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_61'><span class='gform-field-label__text'>What is your current living situation?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_61' id='input_35_61' class='large gfield_select'     aria-invalid=\"false\" ><option value='I live on my own and support myself' >I live on my own and support myself<\/option><option value='I live on my own and get support from a friend, family member or support worker' >I live on my own and get support from a friend, family member or support worker<\/option><option value='I live in a group home' >I live in a group home<\/option><option value='I live with my family and\/or friends' >I live with my family and\/or friends<\/option><\/select><\/div><\/div><div id=\"field_35_5\" class=\"gfield gfield--type-Infobox field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gform_infobox exclude gform_infobox_information\"  data-field-class=\"gform_infobox exclude gform_infobox_information\" ><div class='gfield_description'>The following question is about your gender. <\/div><\/div><div id=\"field_35_7\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_7'><span class='gform-field-label__text'>What is your gender?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_35_7' class='large gfield_select'     aria-invalid=\"false\" ><option value='Male' >Male<\/option><option value='Female' >Female<\/option><option value='Other' >Other<\/option><option value='Refuse to answer' >Refuse to answer<\/option><option value='I don&#039;t know' >I don&#039;t know<\/option><\/select><\/div><\/div><div id=\"field_35_67\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_67'><span class='gform-field-label__text'>If other, please tell us your gender (optional):<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_35_67' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_35_8\" class=\"gfield gfield--type-Infobox field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gform_infobox exclude gform_infobox_information\"  data-field-class=\"gform_infobox exclude gform_infobox_information\" ><div class='gfield_description'>The next questions are about your health.<\/div><\/div><div id=\"field_35_9\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_9'><span class='gform-field-label__text'>In general, would you say your health is&#8230;?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_9' id='input_35_9' class='large gfield_select'     aria-invalid=\"false\" ><option value='Excellent' >Excellent<\/option><option value='Very good' >Very good<\/option><option value='Good' >Good<\/option><option value='Fair' >Fair<\/option><option value='Poor' >Poor<\/option><option value='Refuse to answer' >Refuse to answer<\/option><option value='I don&#039;t know' >I don&#039;t know<\/option><\/select><\/div><\/div><div id=\"field_35_10\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_10'><span class='gform-field-label__text'>Our mental health is how we think, feel and act each day. In general, would you say your mental health is&#8230;?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_10' id='input_35_10' class='large gfield_select'     aria-invalid=\"false\" ><option value='Excellent' >Excellent<\/option><option value='Very good' >Very good<\/option><option value='Good' >Good<\/option><option value='Fair' >Fair<\/option><option value='Poor' >Poor<\/option><option value='Refuse to answer' >Refuse to answer<\/option><option value='I don&#039;t know' >I don&#039;t know<\/option><\/select><\/div><\/div><div id=\"field_35_11\" class=\"gfield gfield--type-Infobox field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gform_infobox exclude gform_infobox_information\"  data-field-class=\"gform_infobox exclude gform_infobox_information\" ><div class='gfield_description'>The next questions are about your height and weight.<\/div><\/div><div id=\"field_35_14\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_14'><span class='gform-field-label__text'>How tall are you without shoes on (feet and inches, example: if you&#039;re 5ft 11in tall, write 5ft 11in)?<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_35_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_35_68\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_68'><span class='gform-field-label__text'>How much do you weigh in pounds (lbs, example if you weigh 120lbs, write 120lbs)?<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_35_68' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_35_16\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_16'><span class='gform-field-label__text'>Do you consider yourself&#8230;?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_16' id='input_35_16' class='large gfield_select'     aria-invalid=\"false\" ><option value='Overweight' >Overweight<\/option><option value='Underweight' >Underweight<\/option><option value='Just about right' >Just about right<\/option><option value='Refuse to answer' >Refuse to answer<\/option><option value='I don&#039;t know' >I don&#039;t know<\/option><\/select><\/div><\/div><div id=\"field_35_17\" class=\"gfield gfield--type-Infobox field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gform_infobox exclude gform_infobox_information\"  data-field-class=\"gform_infobox exclude gform_infobox_information\" ><div class='gfield_description'>The following questions are about  health conditions.<\/div><\/div><fieldset id=\"field_35_19\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Have you been diagnosed with any of the following conditions? Please check all that apply.<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_35_19'><div class='gchoice gchoice_35_19_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.1' type='checkbox'  value='Fibromyalgia'  id='choice_35_19_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_19_1' id='label_35_19_1' class='gform-field-label gform-field-label--type-inline'>Fibromyalgia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_19_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.2' type='checkbox'  value='Arthritis'  id='choice_35_19_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_19_2' id='label_35_19_2' class='gform-field-label gform-field-label--type-inline'>Arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_19_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.3' type='checkbox'  value='Back problems'  id='choice_35_19_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_19_3' id='label_35_19_3' class='gform-field-label gform-field-label--type-inline'>Back problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_19_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.4' type='checkbox'  value='Osteoporosis'  id='choice_35_19_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_19_4' id='label_35_19_4' class='gform-field-label gform-field-label--type-inline'>Osteoporosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_19_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.5' type='checkbox'  value='High blood pressure'  id='choice_35_19_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_19_5' id='label_35_19_5' class='gform-field-label gform-field-label--type-inline'>High blood pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_19_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.6' type='checkbox'  value='High cholesterol'  id='choice_35_19_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_19_6' id='label_35_19_6' class='gform-field-label gform-field-label--type-inline'>High cholesterol<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_19_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.7' type='checkbox'  value='Heart disease'  id='choice_35_19_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_19_7' id='label_35_19_7' class='gform-field-label gform-field-label--type-inline'>Heart disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_19_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.8' type='checkbox'  value='Stroke'  id='choice_35_19_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_19_8' id='label_35_19_8' class='gform-field-label gform-field-label--type-inline'>Stroke<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_19_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.9' type='checkbox'  value='Diabetes'  id='choice_35_19_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_19_9' id='label_35_19_9' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_19_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.11' type='checkbox'  value='Cancer'  id='choice_35_19_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_19_11' id='label_35_19_11' class='gform-field-label gform-field-label--type-inline'>Cancer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_19_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.12' type='checkbox'  value='Alzheimer&#039;s Disease or dementia'  id='choice_35_19_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_19_12' id='label_35_19_12' class='gform-field-label gform-field-label--type-inline'>Alzheimer&#8217;s Disease or dementia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_19_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.13' type='checkbox'  value='Chronic fatigue'  id='choice_35_19_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_19_13' id='label_35_19_13' class='gform-field-label gform-field-label--type-inline'>Chronic fatigue<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_19_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.14' type='checkbox'  value='Depression, bipolar disorder, mania'  id='choice_35_19_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_19_14' id='label_35_19_14' class='gform-field-label gform-field-label--type-inline'>Depression, bipolar disorder, mania<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_19_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.15' type='checkbox'  value='Anxiety disorder, phobia, obsessive-compulsive disorder or panic disorder'  id='choice_35_19_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_19_15' id='label_35_19_15' class='gform-field-label gform-field-label--type-inline'>Anxiety disorder, phobia, obsessive-compulsive disorder or panic disorder<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_35_20\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_20'><span class='gform-field-label__text'>Do you have any difficulty seeing (even when wearing glasses or contact lenses)?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_20' id='input_35_20' class='large gfield_select'     aria-invalid=\"false\" ><option value='No' >No<\/option><option value='Sometimes' >Sometimes<\/option><option value='Often' >Often<\/option><option value='Always' >Always<\/option><\/select><\/div><\/div><div id=\"field_35_21\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_21'><span class='gform-field-label__text'>Do you have any difficulty hearing (even when using a hearing aid)?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_21' id='input_35_21' class='large gfield_select'     aria-invalid=\"false\" ><option value='No' >No<\/option><option value='Sometimes' >Sometimes<\/option><option value='Often' >Often<\/option><option value='Always' >Always<\/option><\/select><\/div><\/div><div id=\"field_35_22\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_22'><span class='gform-field-label__text'>Do you have any difficulty walking, using stairs, using your hands or fingers or doing other physical activities?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_22' id='input_35_22' class='large gfield_select'     aria-invalid=\"false\" ><option value='No' >No<\/option><option value='Sometimes' >Sometimes<\/option><option value='Often' >Often<\/option><option value='Always' >Always<\/option><\/select><\/div><\/div><div id=\"field_35_23\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_23'><span class='gform-field-label__text'>Do you have any emotional, psychological or mental health conditions?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_23' id='input_35_23' class='large gfield_select'     aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='I&#039;m not sure' >I&#039;m not sure<\/option><\/select><\/div><\/div><div id=\"field_35_24\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_24'><span class='gform-field-label__text'>Do you wear glasses or contact lenses to improve your vision?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_24' id='input_35_24' class='large gfield_select'     aria-invalid=\"false\" ><option value='No' >No<\/option><option value='Sometimes' >Sometimes<\/option><option value='Often' >Often<\/option><option value='Always' >Always<\/option><\/select><\/div><\/div><div id=\"field_35_25\" class=\"gfield gfield--type-Infobox field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gform_infobox exclude gform_infobox_information\"  data-field-class=\"gform_infobox exclude gform_infobox_information\" ><div class='gfield_description'>The following questions will ask you about sleep<\/div><\/div><div id=\"field_35_27\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_27'><span class='gform-field-label__text'>How long do you usually spend sleeping each night (in hours, example: if you sleep 8hrs a night, write 8hrs)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_35_27' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_35_26\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_26'><span class='gform-field-label__text'>How often do you have trouble going to sleep or staying asleep?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_26' id='input_35_26' class='large gfield_select'     aria-invalid=\"false\" ><option value='Never' >Never<\/option><option value='Rarely' >Rarely<\/option><option value='Sometimes' >Sometimes<\/option><option value='Most of the time' >Most of the time<\/option><option value='All of the time' >All of the time<\/option><option value='I don&#039;t know' >I don&#039;t know<\/option><option value='' ><\/option><\/select><\/div><\/div><div id=\"field_35_28\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_28'><span class='gform-field-label__text'>How often do you find it difficult to stay awake when you want to?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_28' id='input_35_28' class='large gfield_select'     aria-invalid=\"false\" ><option value='Never' >Never<\/option><option value='Rarely' >Rarely<\/option><option value='Sometimes' >Sometimes<\/option><option value='Most of the time' >Most of the time<\/option><option value='All of the time' >All of the time<\/option><option value='I don&#039;t know' >I don&#039;t know<\/option><\/select><\/div><\/div><div id=\"field_35_29\" class=\"gfield gfield--type-Infobox field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gform_infobox exclude gform_infobox_information\"  data-field-class=\"gform_infobox exclude gform_infobox_information\" ><div class='gfield_description'>These next questions are about the foods you eat and drink.<\/div><\/div><div id=\"field_35_32\" class=\"gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_32'><span class='gform-field-label__text'>Do you know what Canada&#039;s Food Guide is?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_32' id='input_35_32' class='large gfield_select'     aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='' ><\/option><\/select><\/div><\/div><div id=\"field_35_30\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_30'><span class='gform-field-label__text'>Do you understand Canada&#039;s Food Guide?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_30' id='input_35_30' class='large gfield_select'     aria-invalid=\"false\" ><option value='Yes, Canada\u2019s Food Guide is easy to understand' >Yes, Canada\u2019s Food Guide is easy to understand<\/option><option value='I have an idea but I\u2019m still confused on how to achieve the recommendations' >I have an idea but I\u2019m still confused on how to achieve the recommendations<\/option><option value='No, Canada\u2019s Food Guide is hard to understand' >No, Canada\u2019s Food Guide is hard to understand<\/option><option value='I haven&#039;t used Canada&#039;s Food Guide' >I haven&#039;t used Canada&#039;s Food Guide<\/option><\/select><\/div><\/div><div id=\"field_35_62\" class=\"gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_62'><span class='gform-field-label__text'>Can you afford to buy healthy foods (fruits and vegetables, whole grains, lean meat) from the grocery store?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_62' id='input_35_62' class='large gfield_select'     aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='I don&#039;t know' >I don&#039;t know<\/option><\/select><\/div><\/div><div id=\"field_35_31\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_31'><span class='gform-field-label__text'>In the last month, did you eat dark green vegetables such as broccoli, green beans, peas, green peppers, or spinach?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_31' id='input_35_31' class='large gfield_select'     aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='I don&#039;t know' >I don&#039;t know<\/option><\/select><\/div><\/div><div id=\"field_35_33\" class=\"gfield gfield--type-Infobox field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gform_infobox exclude gform_infobox_information\"  data-field-class=\"gform_infobox exclude gform_infobox_information\" ><div class='gfield_description'>The following questions are about smoking.<\/div><\/div><div id=\"field_35_34\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_34'><span class='gform-field-label__text'>In the past 30 days, did you smoke any cigarettes?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_34' id='input_35_34' class='large gfield_select'     aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='I don&#039;t know' >I don&#039;t know<\/option><\/select><\/div><\/div><div id=\"field_35_35\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_35'><span class='gform-field-label__text'>In the past 30 days, did you use an e-cigarette or vaping device?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_35' id='input_35_35' class='large gfield_select'     aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='I don&#039;t know' >I don&#039;t know<\/option><\/select><\/div><\/div><div id=\"field_35_36\" class=\"gfield gfield--type-Infobox field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gform_infobox exclude gform_infobox_information\"  data-field-class=\"gform_infobox exclude gform_infobox_information\" ><div class='gfield_description'>The following questions are about  physical activities done in the last 7 days.<\/div><\/div><div id=\"field_35_37\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_37'><span class='gform-field-label__text'>In the last 7 days, did you do any physical activities such as walking, cycling or sports that made you sweat and breathe harder?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_37' id='input_35_37' class='large gfield_select'     aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='I don&#039;t know' >I don&#039;t know<\/option><\/select><\/div><\/div><div id=\"field_35_39\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_39'><span class='gform-field-label__text'>In the last 7 days, how many hours did you spend doing activities that made you sweat and breathe harder?<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_35_39' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_35_38\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_38'><span class='gform-field-label__text'>How much time PER DAY do you spend watching television, using a computer, tablet, or phone or an electronic device with a screen?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_38' id='input_35_38' class='large gfield_select'     aria-invalid=\"false\" ><option value='2 hours or less per day' >2 hours or less per day<\/option><option value='More than 2 hours but less than 4 hours' >More than 2 hours but less than 4 hours<\/option><option value='4 hours to less than 6 hours' >4 hours to less than 6 hours<\/option><option value='6 hours to less than 8 hours' >6 hours to less than 8 hours<\/option><option value='8 hours or more per day' >8 hours or more per day<\/option><option value='I don&#039;t know' >I don&#039;t know<\/option><\/select><\/div><\/div><div id=\"field_35_40\" class=\"gfield gfield--type-Infobox field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gform_infobox exclude gform_infobox_information\"  data-field-class=\"gform_infobox exclude gform_infobox_information\" ><div class='gfield_description'>The following questions are about mental health and your social relationships<\/div><\/div><div id=\"field_35_41\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_41'><span class='gform-field-label__text'>Over the last two weeks, have you felt down, depressed or hopeless?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_41' id='input_35_41' class='large gfield_select'     aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='I don&#039;t know' >I don&#039;t know<\/option><\/select><\/div><\/div><div id=\"field_35_42\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_42'><span class='gform-field-label__text'>Do you know what resources are available to you when\/if you are feeling down, depressed or hopeless?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_42' id='input_35_42' class='large gfield_select'     aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='I don&#039;t know' >I don&#039;t know<\/option><\/select><\/div><\/div><div id=\"field_35_43\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_43'><span class='gform-field-label__text'>Do you have a friend, family member or close relationship that you can talk to when you feel sad?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_43' id='input_35_43' class='large gfield_select'     aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='I don&#039;t know' >I don&#039;t know<\/option><\/select><\/div><\/div><div id=\"field_35_44\" class=\"gfield gfield--type-Infobox field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gform_infobox exclude gform_infobox_information\"  data-field-class=\"gform_infobox exclude gform_infobox_information\" ><div class='gfield_description'>The following questions will ask you about what health programs at Special Olympics Ontario. We want to know what health programs are going to be the most useful for you. <\/div><\/div><div id=\"field_35_66\" class=\"gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_66'><span class='gform-field-label__text'>Are you a Special Olympics Ontario athlete?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_66' id='input_35_66' class='large gfield_select'     aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_35_56\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_56'><span class='gform-field-label__text'>Have you returned to Special Olympics programs after the COVID-19 pandemic?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_56' id='input_35_56' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_35_57\" class=\"gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_57'><span class='gform-field-label__text'>What has it been like returning to Special Olympics programs?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_57' id='input_35_57' class='large gfield_select'     aria-invalid=\"false\" ><option value='Practices and games feel easier than before the pandemic' >Practices and games feel easier than before the pandemic<\/option><option value='Practices and games feel the same as before the pandemic' >Practices and games feel the same as before the pandemic<\/option><option value='Practices and games feel harder than before the pandemic' >Practices and games feel harder than before the pandemic<\/option><\/select><\/div><\/div><div id=\"field_35_60\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_60'><span class='gform-field-label__text'>Please tell us more about why you haven&#039;t returned to Special Olympics programs:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_35_60' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_35_45\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_45'><span class='gform-field-label__text'>I am looking for more opportunities to receive healthcare.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_45' id='input_35_45' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='I don&#039;t know' >I don&#039;t know<\/option><\/select><\/div><\/div><div id=\"field_35_47\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_47'><span class='gform-field-label__text'>I would like opportunities to receive a Healthy Athletes screening near me.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_47' id='input_35_47' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='I don&#039;t know' >I don&#039;t know<\/option><\/select><\/div><\/div><div id=\"field_35_48\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_48'><span class='gform-field-label__text'>I would like to attend workshops and presentations that teach me more about health and wellness behaviours such as healthy eating and maintaining positive mental health.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_48' id='input_35_48' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='I don&#039;t know' >I don&#039;t know<\/option><\/select><\/div><\/div><fieldset id=\"field_35_49\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Please select the Healthy Athletes screenings that are most valuable to you (select all that apply)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_35_49'><div class='gchoice gchoice_35_49_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.1' type='checkbox'  value='Special Smiles (dental and oral health)'  id='choice_35_49_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_49_1' id='label_35_49_1' class='gform-field-label gform-field-label--type-inline'>Special Smiles (dental and oral health)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_49_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.2' type='checkbox'  value='Opening Eyes (eye health)'  id='choice_35_49_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_49_2' id='label_35_49_2' class='gform-field-label gform-field-label--type-inline'>Opening Eyes (eye health)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_49_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.3' type='checkbox'  value='FunFitness (fitness and physiotherapy)'  id='choice_35_49_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_49_3' id='label_35_49_3' class='gform-field-label gform-field-label--type-inline'>FunFitness (fitness and physiotherapy)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_49_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.4' type='checkbox'  value='MedFest (general check-ups)'  id='choice_35_49_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_49_4' id='label_35_49_4' class='gform-field-label gform-field-label--type-inline'>MedFest (general check-ups)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_49_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.5' type='checkbox'  value='FitFeet (feet health)'  id='choice_35_49_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_49_5' id='label_35_49_5' class='gform-field-label gform-field-label--type-inline'>FitFeet (feet health)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_49_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.6' type='checkbox'  value='Health Promotion (health, wellness, healthy eating, sun safety, sexual health)'  id='choice_35_49_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_49_6' id='label_35_49_6' class='gform-field-label gform-field-label--type-inline'>Health Promotion (health, wellness, healthy eating, sun safety, sexual health)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_35_50\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Please select each type of healthcare provider that you\u2019ve visited in the last 6 months.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_35_50'><div class='gchoice gchoice_35_50_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.1' type='checkbox'  value='Dentist (teeth)'  id='choice_35_50_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_50_1' id='label_35_50_1' class='gform-field-label gform-field-label--type-inline'>Dentist (teeth)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_50_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.2' type='checkbox'  value='Optometrist (eyes)'  id='choice_35_50_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_50_2' id='label_35_50_2' class='gform-field-label gform-field-label--type-inline'>Optometrist (eyes)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_50_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.3' type='checkbox'  value='Physiotherapist (fitness)'  id='choice_35_50_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_50_3' id='label_35_50_3' class='gform-field-label gform-field-label--type-inline'>Physiotherapist (fitness)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_50_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.4' type='checkbox'  value='Doctor'  id='choice_35_50_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_50_4' id='label_35_50_4' class='gform-field-label gform-field-label--type-inline'>Doctor<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_50_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.5' type='checkbox'  value='Podiatrist\/Chiropodist (feet health)'  id='choice_35_50_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_50_5' id='label_35_50_5' class='gform-field-label gform-field-label--type-inline'>Podiatrist\/Chiropodist (feet health)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_50_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.6' type='checkbox'  value='Public Health Nurse (sexual health, vaccinations)'  id='choice_35_50_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_50_6' id='label_35_50_6' class='gform-field-label gform-field-label--type-inline'>Public Health Nurse (sexual health, vaccinations)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_50_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.7' type='checkbox'  value='I have not visited any of these healthcare providers'  id='choice_35_50_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_50_7' id='label_35_50_7' class='gform-field-label gform-field-label--type-inline'>I have not visited any of these healthcare providers<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_35_51\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Please tell us more about your current health needs and desires. Select all that apply.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_35_51'><div class='gchoice gchoice_35_51_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.1' type='checkbox'  value='I\u2019d like to know more about how to keep my teeth healthy and clean'  id='choice_35_51_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_51_1' id='label_35_51_1' class='gform-field-label gform-field-label--type-inline'>I\u2019d like to know more about how to keep my teeth healthy and clean<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_51_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.2' type='checkbox'  value='I\u2019d like to know more about how to keep my eyes healthy and clean'  id='choice_35_51_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_51_2' id='label_35_51_2' class='gform-field-label gform-field-label--type-inline'>I\u2019d like to know more about how to keep my eyes healthy and clean<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_51_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.3' type='checkbox'  value='I\u2019d like to know more about stretching and flexibility exercises'  id='choice_35_51_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_51_3' id='label_35_51_3' class='gform-field-label gform-field-label--type-inline'>I\u2019d like to know more about stretching and flexibility exercises<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_51_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.4' type='checkbox'  value='I\u2019d like a check-up from a doctor who knows how to support me'  id='choice_35_51_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_51_4' id='label_35_51_4' class='gform-field-label gform-field-label--type-inline'>I\u2019d like a check-up from a doctor who knows how to support me<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_51_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.5' type='checkbox'  value='I\u2019d like to know more about how to keep my feet healthy'  id='choice_35_51_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_51_5' id='label_35_51_5' class='gform-field-label gform-field-label--type-inline'>I\u2019d like to know more about how to keep my feet healthy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_51_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.6' type='checkbox'  value='I want more information about healthy eating, sleep, and physical activity'  id='choice_35_51_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_51_6' id='label_35_51_6' class='gform-field-label gform-field-label--type-inline'>I want more information about healthy eating, sleep, and physical activity<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_35_51_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.7' type='checkbox'  value='I do not have any current health needs'  id='choice_35_51_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_35_51_7' id='label_35_51_7' class='gform-field-label gform-field-label--type-inline'>I do not have any current health needs<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_35_65\" class=\"gfield gfield--type-Infobox gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gform_infobox exclude gform_infobox_information\"  data-field-class=\"gform_infobox exclude gform_infobox_information\" ><div class='gfield_description'>The following questions will help us learn a little bit more about you<\/div><\/div><div id=\"field_35_53\" class=\"gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_53'><span class='gform-field-label__text'>Which of the following best describes you?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_53' id='input_35_53' class='large gfield_select'     aria-invalid=\"false\" ><option value='Asian' >Asian<\/option><option value='Black' >Black<\/option><option value='Hispanic or Latino' >Hispanic or Latino<\/option><option value='Indigenous' >Indigenous<\/option><option value='White or Caucasian' >White or Caucasian<\/option><option value='Multiple ethnic groups' >Multiple ethnic groups<\/option><option value='Prefer not to answer' >Prefer not to answer<\/option><\/select><\/div><\/div><div id=\"field_35_54\" class=\"gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_54'><span class='gform-field-label__text'>Which of the following best describes you?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_54' id='input_35_54' class='large gfield_select'     aria-invalid=\"false\" ><option value='Heterosexual (straight)' >Heterosexual (straight)<\/option><option value='Gay' >Gay<\/option><option value='Lesbian' >Lesbian<\/option><option value='Bisexual' >Bisexual<\/option><option value='Other' >Other<\/option><option value='Prefer not to answer' >Prefer not to answer<\/option><\/select><\/div><\/div><div id=\"field_35_55\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_35_55'><span class='gform-field-label__text'>If other, please tell us:<\/span><\/label><div class='ginput_container 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