{"id":3550,"date":"2020-12-15T01:15:02","date_gmt":"2020-12-15T06:15:02","guid":{"rendered":"https:\/\/www.merbleuedental.com\/?page_id=3550"},"modified":"2023-08-23T10:04:48","modified_gmt":"2023-08-23T14:04:48","slug":"antecedents-medicaux-mis-a-jour","status":"publish","type":"page","link":"https:\/\/www.merbleuedental.com\/fr\/antecedents-medicaux-mis-a-jour\/","title":{"rendered":"Ant\u00e9c\u00e9dents m\u00e9dicaux mis \u00e0 jour"},"content":{"rendered":"<p>[et_pb_section fb_built=\u00a0\u00bb1&Prime; fullwidth=\u00a0\u00bbon\u00a0\u00bb _builder_version=\u00a0\u00bb4.16&Prime; global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_fullwidth_header title=\u00a0\u00bbAnt\u00e9c\u00e9dents m\u00e9dicaux mis \u00e0 jour\u00a0\u00bb subhead=\u00a0\u00bbCoordonn\u00e9es des patients\u00a0\u00bb header_fullscreen=\u00a0\u00bbon\u00a0\u00bb _builder_version=\u00a0\u00bb4.18.0&Prime; title_font=\u00a0\u00bb|700|||||||\u00a0\u00bb title_text_color=\u00a0\u00bb#000000&Prime; title_font_size=\u00a0\u00bb39px\u00a0\u00bb subhead_text_color=\u00a0\u00bb#000000&Prime; subhead_font_size=\u00a0\u00bb24px\u00a0\u00bb subhead_line_height=\u00a0\u00bb2.3em\u00a0\u00bb background_image=\u00a0\u00bbhttps:\/\/www.merbleuedental.com\/wp-content\/uploads\/2023\/06\/forms-banner.jpg\u00a0\u00bb background_position=\u00a0\u00bbcenter_right\u00a0\u00bb custom_button_one=\u00a0\u00bbon\u00a0\u00bb button_one_custom_padding=\u00a0\u00bb10px|30px|10px|30px|true|true\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][\/et_pb_fullwidth_header][\/et_pb_section][et_pb_section fb_built=\u00a0\u00bb1&Prime; admin_label=\u00a0\u00bbsection\u00a0\u00bb _builder_version=\u00a0\u00bb4.16&Prime; global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_row admin_label=\u00a0\u00bbligne\u00a0\u00bb _builder_version=\u00a0\u00bb4.16&Prime; background_size=\u00a0\u00bbinitial\u00a0\u00bb background_position=\u00a0\u00bbtop_left\u00a0\u00bb background_repeat=\u00a0\u00bbrepeat\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_column type=\u00a0\u00bb4_4&Prime; _builder_version=\u00a0\u00bb4.16&Prime; custom_padding=\u00a0\u00bb|||\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb custom_padding__hover=\u00a0\u00bb|||\u00a0\u00bb][et_pb_text admin_label=\u00a0\u00bbText\u00a0\u00bb _builder_version=\u00a0\u00bb4.18.0&Prime; text_font_size=\u00a0\u00bb15px\u00a0\u00bb text_line_height=\u00a0\u00bb1.8em\u00a0\u00bb header_font=\u00a0\u00bb|600|||||||\u00a0\u00bb header_2_font=\u00a0\u00bb|600|||||||\u00a0\u00bb background_size=\u00a0\u00bbinitial\u00a0\u00bb background_position=\u00a0\u00bbtop_left\u00a0\u00bb background_repeat=\u00a0\u00bbrepeat\u00a0\u00bb hover_enabled=\u00a0\u00bb0&Prime; global_colors_info=\u00a0\u00bb{}\u00a0\u00bb sticky_enabled=\u00a0\u00bb0&Prime;]<\/p>\n<h2>Coordonn\u00e9es des patients<\/h2>\n<p>Si vous \u00eates d\u00e9j\u00e0 un patient, veillez \u00e0 nous informer de tout changement concernant votre \u00e9tat de sant\u00e9. Les informations suivantes sont n\u00e9cessaires pour nous permettre de vous fournir les meilleurs soins dentaires possibles. Toutes les informations sont strictement priv\u00e9es et sont prot\u00e9g\u00e9es par le principe de la confidentialit\u00e9 entre le m\u00e9decin et le patient.[\/et_pb_text][et_pb_text _builder_version=\u00a0\u00bb4.18.0&Prime; _module_preset=\u00a0\u00bbdefault\u00a0\u00bb text_text_color=\u00a0\u00bb#FFFFFF\u00a0\u00bb header_2_text_color=\u00a0\u00bb#FFFFFF\u00a0\u00bb background_color=\u00a0\u00bb#9c2066&Prime; custom_padding=\u00a0\u00bb|30px||30px|false|true\u00a0\u00bb border_radii=\u00a0\u00bbon|20px|20px|20px|20px\u00a0\u00bb box_shadow_style=\u00a0\u00bbpreset1&Prime; box_shadow_vertical=\u00a0\u00bb0px\u00a0\u00bb box_shadow_blur=\u00a0\u00bb14px\u00a0\u00bb box_shadow_color=\u00a0\u00bbrgba(0,0,0,0.2)\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]<\/p>\n<script>\nvar 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class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_5' id='gform_5'  action='\/fr\/wp-json\/wp\/v2\/pages\/3550#gf_5' data-formid='5' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LeCWBUiAAAAANv34xcxvYKHX6-NK2IdU12ogpU2' data-tabindex='0'><input id=\"input_3e4bd660fbbdde3592fb2f320f8ce751\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_3e4bd660fbbdde3592fb2f320f8ce751\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_5_4\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Type de patient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_4'>\n\t\t\t<div class='gchoice gchoice_5_4_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='Adulte'  id='choice_5_4_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_4_0' id='label_5_4_0' class='gform-field-label gform-field-label--type-inline'>Adulte<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_4_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='Enfant'  id='choice_5_4_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_4_1' id='label_5_4_1' class='gform-field-label gform-field-label--type-inline'>Enfant<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_4_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='Adulte sous tutelle'  id='choice_5_4_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_4_2' id='label_5_4_2' class='gform-field-label gform-field-label--type-inline'>Adulte sous tutelle<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_61\" class=\"gfield gfield--type-name gfield--width-full field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nom du tuteur<\/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_5_61'>\n                            \n                            <span id='input_5_61_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_61.3' id='input_5_61_3' value=''   aria-required='false'   placeholder='Pr\u00e9nom'  \/>\n                                                    <label for='input_5_61_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_61_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_61.6' id='input_5_61_6' value=''   aria-required='false'   placeholder='Nom de famille'  \/>\n                                                    <label for='input_5_61_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_5_5\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_5'>Courriel<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_5_5' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_5_6\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Genres<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_6'>\n\t\t\t<div class='gchoice gchoice_5_6_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Homme'  id='choice_5_6_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_6_0' id='label_5_6_0' class='gform-field-label gform-field-label--type-inline'>Homme<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_6_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Femme'  id='choice_5_6_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_6_1' id='label_5_6_1' class='gform-field-label gform-field-label--type-inline'>Femme<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_6_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Autre'  id='choice_5_6_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_6_2' id='label_5_6_2' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_63\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_63'>Veuillez expliquer plus de d\u00e9tails<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_63' id='input_5_63' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_7\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nom du patient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/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_5_7'>\n                            \n                            <span id='input_5_7_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.3' id='input_5_7_3' value=''   aria-required='true'   placeholder='Pr\u00e9nom'  \/>\n                                                    <label for='input_5_7_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_7_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.6' id='input_5_7_6' value=''   aria-required='true'   placeholder='Nom de famille'  \/>\n                                                    <label for='input_5_7_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_5_8\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_8'>Date de naissance<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_8' id='input_5_8' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_5_8_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_8_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_8' class='gform_hidden' value='https:\/\/www.merbleuedental.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_5_10\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_10'>Adresse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_5_10' type='text' value='' class='large'    placeholder='Adresse 1' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_13\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_13'>Province<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_13' id='input_5_13' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>S\u00e9lectionnez la province<\/option><option value='Alberta' >Alberta<\/option><option value='Colombie britannique' >Colombie britannique<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Terre-Neuve-et-Labrador' >Terre-Neuve-et-Labrador<\/option><option value='Territoires du nord-ouest' >Territoires du nord-ouest<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='\u00cele-du-Prince-\u00c9douard' >\u00cele-du-Prince-\u00c9douard<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select><\/div><\/div><div id=\"field_5_12\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_12'>Code Postal<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_5_12' type='text' value='' class='large'    placeholder='Code Postal'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_57\" class=\"gfield gfield--type-phone 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_5_57'>Num\u00e9ro de t\u00e9l\u00e9phone cellulaire<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_57' id='input_5_57' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_58\" class=\"gfield gfield--type-phone 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_5_58'>Num\u00e9ro de t\u00e9l\u00e9phone \u00e0 la maison<\/label><div class='ginput_container ginput_container_phone'><input name='input_58' id='input_5_58' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_59\" class=\"gfield gfield--type-phone 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_5_59'>Num\u00e9ro de t\u00e9l\u00e9phone au travail<\/label><div class='ginput_container ginput_container_phone'><input name='input_59' id='input_5_59' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_17\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Le meilleur num\u00e9ro pour vous joindre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_17'>\n\t\t\t<div class='gchoice gchoice_5_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Num\u00e9ro de t\u00e9l\u00e9phone \u00e0 la maison'  id='choice_5_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_17_0' id='label_5_17_0' class='gform-field-label gform-field-label--type-inline'>Num\u00e9ro de t\u00e9l\u00e9phone \u00e0 la maison<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Num\u00e9ro cellulaire'  id='choice_5_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_17_1' id='label_5_17_1' class='gform-field-label gform-field-label--type-inline'>Num\u00e9ro cellulaire<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_17_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Num\u00e9ro de t\u00e9l\u00e9phone au travail'  id='choice_5_17_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_17_2' id='label_5_17_2' class='gform-field-label gform-field-label--type-inline'>Num\u00e9ro de t\u00e9l\u00e9phone au travail<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_18\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00cates-vous actuellement trait\u00e9 pour une condition m\u00e9dicale ou avez-vous \u00e9t\u00e9 trait\u00e9 au cours de la derni\u00e8re ann\u00e9e ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_18'>\n\t\t\t<div class='gchoice gchoice_5_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Oui'  id='choice_5_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_18_0' id='label_5_18_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Non'  id='choice_5_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_18_1' id='label_5_18_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_19\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_19'>Veuillez expliquer plus de d\u00e9tails<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_19' id='input_5_19' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_52\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_52'>Quand avez-vous effectu\u00e9 votre dernier examen de sant\u00e9 ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_5_52' type='text' value='' class='large'    placeholder='mm\/jj\/aa' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Y a-t-il eu des changements dans votre \u00e9tat de sant\u00e9 g\u00e9n\u00e9ral au cours de la derni\u00e8re ann\u00e9e ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_22'>\n\t\t\t<div class='gchoice gchoice_5_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Oui'  id='choice_5_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_22_0' id='label_5_22_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Non'  id='choice_5_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_22_1' id='label_5_22_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_23\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_23'>Veuillez expliquer plus de d\u00e9tails<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_23' id='input_5_23' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_24\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Prenez-vous des m\u00e9dicaments, des m\u00e9dicaments sans ordonnance ou des suppl\u00e9ments \u00e0 base de plantes de toute sorte ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_24'>\n\t\t\t<div class='gchoice gchoice_5_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Oui'  id='choice_5_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_24_0' id='label_5_24_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Non'  id='choice_5_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_24_1' id='label_5_24_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_25\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_25'>Veuillez expliquer plus de d\u00e9tails<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_25' id='input_5_25' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >As tu des allergies?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_26'>\n\t\t\t<div class='gchoice gchoice_5_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Oui'  id='choice_5_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_26_0' id='label_5_26_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Non'  id='choice_5_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_26_1' id='label_5_26_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_27\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_27'>Veuillez pr\u00e9ciser les allergies ci-dessous<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_27' id='input_5_27' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_28\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous d\u00e9j\u00e0 eu une r\u00e9action particuli\u00e8re ou ind\u00e9sirable \u00e0 des m\u00e9dicaments ou \u00e0 des injections ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_28'>\n\t\t\t<div class='gchoice gchoice_5_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Oui'  id='choice_5_28_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_28_0' id='label_5_28_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Non'  id='choice_5_28_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_28_1' id='label_5_28_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_29\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_29'>Veuillez expliquer plus de d\u00e9tails<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_29' id='input_5_29' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous ou avez-vous d\u00e9j\u00e0 eu de l&#039;asthme?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_30'>\n\t\t\t<div class='gchoice gchoice_5_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Oui'  id='choice_5_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_30_0' id='label_5_30_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Non'  id='choice_5_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_30_1' id='label_5_30_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_53\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_53'>Veuillez expliquer plus de d\u00e9tails<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_53' id='input_5_53' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_31\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous ou avez-vous d\u00e9j\u00e0 eu des probl\u00e8mes cardiaques ou de pression art\u00e9rielle ?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_31'>\n\t\t\t<div class='gchoice gchoice_5_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Oui'  id='choice_5_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_31_0' id='label_5_31_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Non'  id='choice_5_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_31_1' id='label_5_31_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_54\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_54'>Veuillez expliquer plus de d\u00e9tails<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_54' id='input_5_54' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_32\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous ou avez-vous d\u00e9j\u00e0 eu un remplacement ou une r\u00e9paration d&#039;une valve cardiaque, une infection du c\u0153ur (c.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_32'>\n\t\t\t<div class='gchoice gchoice_5_32_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Oui'  id='choice_5_32_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_32_0' id='label_5_32_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_32_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Non'  id='choice_5_32_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_32_1' id='label_5_32_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_49\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_49'>Veuillez expliquer plus de d\u00e9tails<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_49' id='input_5_49' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_33\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous une articulation proth\u00e9tique ou artificielle?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_33'>\n\t\t\t<div class='gchoice gchoice_5_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Oui'  id='choice_5_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_33_0' id='label_5_33_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Non'  id='choice_5_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_33_1' id='label_5_33_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_50\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_50'>Veuillez expliquer plus de d\u00e9tails<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_50' id='input_5_50' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_34\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous des conditions ou des traitements qui pourraient affecter votre syst\u00e8me immunitaire (par exemple, la leuc\u00e9mie, le SIDA, l&#039;infection par le VIH, la radioth\u00e9rapie, la chimioth\u00e9rapie) ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_34'>\n\t\t\t<div class='gchoice gchoice_5_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Oui'  id='choice_5_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_34_0' id='label_5_34_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Non'  id='choice_5_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_34_1' id='label_5_34_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_51\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_51'>Veuillez expliquer plus de d\u00e9tails<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_51' id='input_5_51' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_35\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous d\u00e9j\u00e0 eu une h\u00e9patite, une jaunisse ou une maladie du foie ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_35'>\n\t\t\t<div class='gchoice gchoice_5_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Oui'  id='choice_5_35_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_35_0' id='label_5_35_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Non'  id='choice_5_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_35_1' id='label_5_35_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_55\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_55'>Veuillez expliquer plus de d\u00e9tails<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_55' id='input_5_55' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 hospitalis\u00e9 pour une maladie ou une op\u00e9ration ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_36'>\n\t\t\t<div class='gchoice gchoice_5_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Oui'  id='choice_5_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_36_0' id='label_5_36_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Non'  id='choice_5_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_36_1' id='label_5_36_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_56\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_56'>Veuillez expliquer plus de d\u00e9tails<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_56' id='input_5_56' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_37\" 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\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Avez-vous ou avez-vous d\u00e9j\u00e0 eu l&#039;un des probl\u00e8mes suivants ? Veuillez cocher tout ce qui s&#039;applique.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_37'><div class='gchoice gchoice_5_37_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.1' type='checkbox'  value='douleur thoracique, angine'  id='choice_5_37_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_1' id='label_5_37_1' class='gform-field-label gform-field-label--type-inline'>douleur thoracique, angine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_37_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.2' type='checkbox'  value='rhumatisme articulaire aigu'  id='choice_5_37_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_2' id='label_5_37_2' class='gform-field-label gform-field-label--type-inline'>rhumatisme articulaire aigu<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_37_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.3' type='checkbox'  value='stimulateur cardiaque'  id='choice_5_37_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_3' id='label_5_37_3' class='gform-field-label gform-field-label--type-inline'>stimulateur cardiaque<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_37_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.4' type='checkbox'  value='corticoth\u00e9rapie'  id='choice_5_37_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_4' id='label_5_37_4' class='gform-field-label gform-field-label--type-inline'>corticoth\u00e9rapie<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_37_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.5' type='checkbox'  value='convulsions (\u00e9pilepsie)'  id='choice_5_37_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_5' id='label_5_37_5' class='gform-field-label gform-field-label--type-inline'>convulsions (\u00e9pilepsie)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_37_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.6' type='checkbox'  value='crise cardiaque'  id='choice_5_37_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_6' id='label_5_37_6' class='gform-field-label gform-field-label--type-inline'>crise cardiaque<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_37_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.7' type='checkbox'  value='prolapsus de la valve mitrale'  id='choice_5_37_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_7' id='label_5_37_7' class='gform-field-label gform-field-label--type-inline'>prolapsus de la valve mitrale<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_37_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.8' type='checkbox'  value='les maladies pulmonaires'  id='choice_5_37_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_8' id='label_5_37_8' class='gform-field-label gform-field-label--type-inline'>les maladies pulmonaires<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_37_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.9' type='checkbox'  value='diab\u00e8te'  id='choice_5_37_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_9' id='label_5_37_9' class='gform-field-label gform-field-label--type-inline'>diab\u00e8te<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_37_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.11' type='checkbox'  value='maladie du rein'  id='choice_5_37_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_11' id='label_5_37_11' class='gform-field-label gform-field-label--type-inline'>maladie du rein<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_37_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.12' type='checkbox'  value='accident vasculaire c\u00e9r\u00e9bral, AIT'  id='choice_5_37_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_12' id='label_5_37_12' class='gform-field-label gform-field-label--type-inline'>accident vasculaire c\u00e9r\u00e9bral, AIT<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_37_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.13' type='checkbox'  value='tuberculose'  id='choice_5_37_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_13' id='label_5_37_13' class='gform-field-label gform-field-label--type-inline'>tuberculose<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_37_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.14' type='checkbox'  value='ulc\u00e8res d&#039;estomac'  id='choice_5_37_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_14' id='label_5_37_14' class='gform-field-label gform-field-label--type-inline'>ulc\u00e8res d'estomac<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_37_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.15' type='checkbox'  value='maladie thyro\u00efdienne'  id='choice_5_37_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_15' id='label_5_37_15' class='gform-field-label gform-field-label--type-inline'>maladie thyro\u00efdienne<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_37_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.16' type='checkbox'  value='essoufflement'  id='choice_5_37_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_16' id='label_5_37_16' class='gform-field-label gform-field-label--type-inline'>essoufflement<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_37_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.17' type='checkbox'  value='souffle au coeur'  id='choice_5_37_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_17' id='label_5_37_17' class='gform-field-label gform-field-label--type-inline'>souffle au coeur<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_37_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.18' type='checkbox'  value='cancer'  id='choice_5_37_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_18' id='label_5_37_18' class='gform-field-label gform-field-label--type-inline'>cancer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_37_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.19' type='checkbox'  value='arthrite'  id='choice_5_37_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_19' id='label_5_37_19' class='gform-field-label gform-field-label--type-inline'>arthrite<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_37_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.21' type='checkbox'  value='consommation de drogue\/alcool\/cannabis ou d\u00e9pendance'  id='choice_5_37_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_21' id='label_5_37_21' class='gform-field-label gform-field-label--type-inline'>consommation de drogue\/alcool\/cannabis ou d\u00e9pendance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_37_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.22' type='checkbox'  value='m\u00e9dicaments contre l&#039;ost\u00e9oporose (par exemple Fosamax, Actonel)'  id='choice_5_37_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_22' id='label_5_37_22' class='gform-field-label gform-field-label--type-inline'>m\u00e9dicaments contre l'ost\u00e9oporose (par exemple Fosamax, Actonel)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_37_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.23' type='checkbox'  value='perte d&#039;audition'  id='choice_5_37_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_23' id='label_5_37_23' class='gform-field-label gform-field-label--type-inline'>perte d'audition<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_37_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.24' type='checkbox'  value='difficulty hearing'  id='choice_5_37_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_24' id='label_5_37_24' class='gform-field-label gform-field-label--type-inline'>difficulty hearing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_37_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.25' type='checkbox'  value='Aucune des choses ci-dessus'  id='choice_5_37_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_37_25' id='label_5_37_25' class='gform-field-label gform-field-label--type-inline'>Aucune des choses ci-dessus<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_38\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Y a-t-il des conditions ou des maladies non \u00e9num\u00e9r\u00e9es ci-dessus que vous avez ou avez eues ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_38'>\n\t\t\t<div class='gchoice gchoice_5_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Oui'  id='choice_5_38_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_38_0' id='label_5_38_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Non'  id='choice_5_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_38_1' id='label_5_38_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_39\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_39'>Veuillez expliquer plus de d\u00e9tails<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_39' id='input_5_39' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_40\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Fumez-vous ou utilisez-vous d&#039;autres produits \u00e0 base de nicotine ?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_40'>\n\t\t\t<div class='gchoice gchoice_5_40_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Oui'  id='choice_5_40_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_40_0' id='label_5_40_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_40_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Non'  id='choice_5_40_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_40_1' id='label_5_40_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_41\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Vous allaitez ou \u00eates enceinte ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_41'>\n\t\t\t<div class='gchoice gchoice_5_41_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Oui'  id='choice_5_41_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_41_0' id='label_5_41_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_41_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Non'  id='choice_5_41_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_41_1' id='label_5_41_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_64\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_64'>Veuillez expliquer plus de d\u00e9tails<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_64' id='input_5_64' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous un handicap ou \u00eates-vous une personne ayant une d\u00e9ficience visuelle<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_43'>\n\t\t\t<div class='gchoice gchoice_5_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Oui'  id='choice_5_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_43_0' id='label_5_43_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Non'  id='choice_5_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_43_1' id='label_5_43_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_44\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_44'>Veuillez expliquer plus de d\u00e9tails<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_44' id='input_5_44' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_45\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Publication g\u00e9n\u00e9rale<\/h2>\n<\/div><div id=\"field_5_46\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Je certifie, soussign\u00e9(e), que j'ai fourni un rapport exact et complet de mes ant\u00e9c\u00e9dents personnels et m\u00e9dico-dentaires au mieux de mes capacit\u00e9s et que je n'ai pas volontairement n\u00e9glig\u00e9 de fournir des informations. J'ai eu la chance de poser des questions et d'obtenir des r\u00e9ponses \u00e0 toute question concernant mes ant\u00e9c\u00e9dents m\u00e9dico-dentaires. J'autorise le dentiste \u00e0 effectuer les proc\u00e9dures de diagnostic n\u00e9cessaires pour d\u00e9terminer le traitement requis. Je comprends que les informations fournies par ou \u00e0 mon m\u00e9decin ou \u00e0 un autre professionnel de la sant\u00e9 peuvent \u00eatre n\u00e9cessaires, et je consens \u00e0 ce que ces informations soient fournies. Je comprends que la responsabilit\u00e9 du paiement des services dentaires pour moi-m\u00eame et les personnes \u00e0 ma charge est mienne, et j'assume la responsabilit\u00e9 des frais associ\u00e9s \u00e0 ces services. J'accepte que la relation entre moi-m\u00eame et le dentiste soit r\u00e9gie et interpr\u00e9t\u00e9e conform\u00e9ment aux lois de la province de l'Ontario.<\/div><div id=\"field_5_47\" class=\"gfield gfield--type-signature gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_47'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_47' id='input_5_47_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_5_47_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_5_47' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: 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Dental<\/a><\/noscript>[\/et_pb_code][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Coordonn\u00e9es des patients Si vous \u00eates d\u00e9j\u00e0 un patient, veillez \u00e0 nous informer de tout changement concernant votre \u00e9tat de sant\u00e9. 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