{"id":9787,"date":"2025-12-26T12:00:22","date_gmt":"2025-12-26T03:00:22","guid":{"rendered":"https:\/\/mrclinic.tokyo\/en\/?page_id=9787"},"modified":"2025-12-26T15:02:54","modified_gmt":"2025-12-26T06:02:54","slug":"cancer-treatment-questionnaire","status":"publish","type":"page","link":"https:\/\/mrclinic.tokyo\/en\/cancer-treatment-questionnaire\/","title":{"rendered":"Cancer Treatment Questionnaire"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"9787\" class=\"elementor elementor-9787\">\n\t\t\t\t<div class=\"elementor-element elementor-element-1ce4bc1e e-flex e-con-boxed e-con e-parent\" data-id=\"1ce4bc1e\" data-element_type=\"container\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-10fa70a8 e-con-full e-flex e-con e-child\" data-id=\"10fa70a8\" data-element_type=\"container\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-5594cd5a elementor-widget elementor-widget-spacer\" data-id=\"5594cd5a\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-2cbfc040 elementor-widget elementor-widget-heading\" data-id=\"2cbfc040\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Cancer Treatment Questionnaire<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-2cc18e74 elementor-widget elementor-widget-spacer\" data-id=\"2cc18e74\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-445b96ff elementor-widget elementor-widget-text-editor\" data-id=\"445b96ff\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>For those wishing to receive cancer treatment, please fill out and submit the questionnaire before your consultation. Sharing your information in advance will help shorten the consultation time and contribute to a more in-depth and productive session.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-7a4e4fba elementor-widget elementor-widget-text-editor\" data-id=\"7a4e4fba\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>\u203bDisclaimer: This form is used to collect information about patients and used for internal purposes only. The information you supply is confidential and will be treated accordingly.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-65a0889e elementor-widget elementor-widget-spacer\" data-id=\"65a0889e\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-806d7c0 e-flex e-con-boxed e-con e-parent\" data-id=\"806d7c0\" data-element_type=\"container\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-4b1fde3 e-con-full e-flex e-con e-child\" data-id=\"4b1fde3\" data-element_type=\"container\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-a51b059 elementor-widget elementor-widget-contact-form-7\" data-id=\"a51b059\" data-element_type=\"widget\" data-widget_type=\"contact-form-7.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-contact-form-7 jet-elements\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f9750-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"9750\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/9787#wpcf7-f9750-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"9750\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f9750-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<div class=\"mrc-contact-form\">\n\t<p><span class=\"part required\">Date of Entry <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"your-entry-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"your-entry-date\" \/><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"part\">Your Information<\/span><br \/>\n<span class=\"required\">Name <\/span><br \/>\n<span><span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span><\/span><br \/>\n<span class=\"required\">Gender <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"your-gender\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"your-gender\" value=\"Male\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"your-gender\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/label><\/span><\/span><\/span> <\/span><br \/>\n<span class=\"required\">Date of Birth <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"your-birthday\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"your-birthday\" \/><\/span><\/span><span> (<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"your-age\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length2\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"your-age\" \/><\/span><\/span><span> years old)<\/span><br \/>\n<span class=\"required\">Nationality <\/span><span> <span class=\"wpcf7-form-control-wrap\" data-name=\"your-nationality\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-nationality\" \/><\/span><\/span>\n\t<\/p>\n\t<p><span>Height <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"your-height\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length2\" min=\"0\" max=\"999\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"your-height\" \/><\/span><\/span><span>cm<\/span><br \/>\n<span>Weight Previously <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"your-preweight\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length2\" min=\"0\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"your-preweight\" \/><\/span><\/span><span>kg \u2192 Now <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"your-nowweight\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length2\" min=\"0\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"your-nowweight\" \/><\/span><\/span><span>kg <\/span><span> (Change <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"your-differenceweight\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length2\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"your-differenceweight\" \/><\/span><\/span><span>kg) <\/span>\n\t<\/p>\n\t<p><span class=\"required\">Address<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-address\" \/><\/span><br \/>\n<span class=\"required\">Phone Number <\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-phonenumber\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"your-phonenumber\" \/><\/span><br \/>\n<span class=\"required\">Email Address <\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span>\n\t<\/p>\n\t<p><span class=\"part\">Cancer History<\/span><br \/>\n<span class=\"section required\">Cancer Location <\/span> (Please check all that apply)<br \/>\n<span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-location\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-location[]\" value=\"Breast\" \/><span class=\"wpcf7-list-item-label\">Breast<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-location[]\" value=\"Lung\" \/><span class=\"wpcf7-list-item-label\">Lung<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-location[]\" value=\"Prostate\" \/><span class=\"wpcf7-list-item-label\">Prostate<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-location[]\" value=\"Colorectal\" \/><span class=\"wpcf7-list-item-label\">Colorectal<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-location[]\" value=\"Stomach\" \/><span class=\"wpcf7-list-item-label\">Stomach<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-location[]\" value=\"Liver\" \/><span class=\"wpcf7-list-item-label\">Liver<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-location[]\" value=\"Pancreas\" \/><span class=\"wpcf7-list-item-label\">Pancreas<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-location[]\" value=\"Skin\" \/><span class=\"wpcf7-list-item-label\">Skin<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-location[]\" value=\"Brain\" \/><span class=\"wpcf7-list-item-label\">Brain<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-location[]\" value=\"Bladder\" \/><span class=\"wpcf7-list-item-label\">Bladder<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-location[]\" value=\"Blood\" \/><span class=\"wpcf7-list-item-label\">Blood<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-location[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"section required\">Cancer Stage <\/span><span> <span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-stage\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"cancer-history-stage\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Stage 0 (Carcinoma in situ)\">Stage 0 (Carcinoma in situ)<\/option><option value=\"Stage I\">Stage I<\/option><option value=\"Stage II\">Stage II<\/option><option value=\"Stage III\">Stage III<\/option><option value=\"Stage IV\">Stage IV<\/option><option value=\"Unknown\">Unknown<\/option><\/select><\/span><\/span><br \/>\n<span class=\"section\">Cancer therapy <\/span><span>Please select the cancer therapy that you have taken<\/span><br \/>\n<span class=\"subsection required\">Surgery<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-surgery\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-surgery\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-surgery\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"\">Year <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-surgery-year\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length4\" min=\"1000\" max=\"9999\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"cancer-history-surgery-year\" \/><\/span> <\/span><span class=\"heading\">Location <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-surgery-location\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cancer-history-surgery-location\" \/><\/span> <\/span><br \/>\n<span class=\"subsection required\">Chemotherapy<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-chemotherapy\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"\">Duration <\/span><span>From <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-chemotherapy-from\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length4\" min=\"1000\" max=\"9999\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"cancer-history-chemotherapy-from\" \/><\/span> <\/span><span>To <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-chemotherapy-to\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length4\" min=\"1000\" max=\"9999\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"cancer-history-chemotherapy-to\" \/><\/span> <\/span><br \/>\n<span class=\"\">Medication <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-chemotherapy-medication\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-medication[]\" value=\"Alkylating Agents\" \/><span class=\"wpcf7-list-item-label\">Alkylating Agents<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-medication[]\" value=\"Antimetabolites\" \/><span class=\"wpcf7-list-item-label\">Antimetabolites<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-medication[]\" value=\"Anti-Tumor Antibiotics\" \/><span class=\"wpcf7-list-item-label\">Anti-Tumor Antibiotics<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-medication[]\" value=\"Topoisomerase Inhibitors\" \/><span class=\"wpcf7-list-item-label\">Topoisomerase Inhibitors<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-medication[]\" value=\"Mitotic Inhibitors\" \/><span class=\"wpcf7-list-item-label\">Mitotic Inhibitors<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-medication[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"\">Effectiveness <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-chemotherapy-effectiveness\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"cancer-history-chemotherapy-effectiveness\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Good\">Good<\/option><option value=\"Poor\">Poor<\/option><option value=\"No Change\">No Change<\/option><\/select><\/span><\/span><br \/>\n<span class=\"\">Side Effects <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-chemotherapy-sideeffects\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"Vomiting\/Nausea\" \/><span class=\"wpcf7-list-item-label\">Vomiting\/Nausea<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"Hair Loss\" \/><span class=\"wpcf7-list-item-label\">Hair Loss<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"Weight Loss\" \/><span class=\"wpcf7-list-item-label\">Weight Loss<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"Diarrhea\" \/><span class=\"wpcf7-list-item-label\">Diarrhea<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"Constipation\" \/><span class=\"wpcf7-list-item-label\">Constipation<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"Numbness\" \/><span class=\"wpcf7-list-item-label\">Numbness<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"Anemia\" \/><span class=\"wpcf7-list-item-label\">Anemia<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"Infection\" \/><span class=\"wpcf7-list-item-label\">Infection<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"Bleeding\" \/><span class=\"wpcf7-list-item-label\">Bleeding<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"Mouth Ulcers\" \/><span class=\"wpcf7-list-item-label\">Mouth Ulcers<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"Skin Disorders\" \/><span class=\"wpcf7-list-item-label\">Skin Disorders<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"Nail Changes\" \/><span class=\"wpcf7-list-item-label\">Nail Changes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"subsection required\">Radiotherapy <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-radiotherapy\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"\">The type(s) of radiotherapy <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-radiotherapy-type\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-type[]\" value=\"Electron Beam\" \/><span class=\"wpcf7-list-item-label\">Electron Beam<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-type[]\" value=\"X-ray (IMRT\/IGRT)\" \/><span class=\"wpcf7-list-item-label\">X-ray (IMRT\/IGRT)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-type[]\" value=\"CyberKnife\" \/><span class=\"wpcf7-list-item-label\">CyberKnife<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-type[]\" value=\"Gamma Knife\" \/><span class=\"wpcf7-list-item-label\">Gamma Knife<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-type[]\" value=\"Proton Beam\" \/><span class=\"wpcf7-list-item-label\">Proton Beam<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-type[]\" value=\"Heavy Ion Beam\" \/><span class=\"wpcf7-list-item-label\">Heavy Ion Beam<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-type[]\" value=\"Interstitial Brachytherapy\" \/><span class=\"wpcf7-list-item-label\">Interstitial Brachytherapy<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-type[]\" value=\"Intracavitary Brachytherapy\" \/><span class=\"wpcf7-list-item-label\">Intracavitary Brachytherapy<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-type[]\" value=\"Internal Radiation Therapy\" \/><span class=\"wpcf7-list-item-label\">Internal Radiation Therapy<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"\">Duration <\/span><span>From <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-radiotherapy-from\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length4\" min=\"1000\" max=\"9999\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"cancer-history-radiotherapy-from\" \/><\/span> <\/span><span>To <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-radiotherapy-to\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length4\" min=\"1000\" max=\"9999\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"cancer-history-radiotherapy-to\" \/><\/span> <\/span><br \/>\n<span class=\"heading\">Location <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-radiotherapy-location\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cancer-history-radiotherapy-location\" \/><\/span><\/span><br \/>\n<span class=\"\">Effectiveness <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-radiotherapy-effectiveness\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"cancer-history-radiotherapy-effectiveness\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Good\">Good<\/option><option value=\"Poor\">Poor<\/option><option value=\"No Change\">No Change<\/option><\/select><\/span><\/span><br \/>\n<span class=\"\">Side Effects <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-radiotherapy-sideeffects\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"Nausea\" \/><span class=\"wpcf7-list-item-label\">Nausea<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"Hair Loss\" \/><span class=\"wpcf7-list-item-label\">Hair Loss<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"Diarrhea\" \/><span class=\"wpcf7-list-item-label\">Diarrhea<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"Mouth Ulcers\" \/><span class=\"wpcf7-list-item-label\">Mouth Ulcers<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"Dry Mouth\" \/><span class=\"wpcf7-list-item-label\">Dry Mouth<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"Taste Disturbance\" \/><span class=\"wpcf7-list-item-label\">Taste Disturbance<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"Difficulty Eating (Esophagitis)\" \/><span class=\"wpcf7-list-item-label\">Difficulty Eating (Esophagitis)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"Pneumonia\" \/><span class=\"wpcf7-list-item-label\">Pneumonia<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"Skin Redness\" \/><span class=\"wpcf7-list-item-label\">Skin Redness<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"Skin Peeling\" \/><span class=\"wpcf7-list-item-label\">Skin Peeling<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"Dermatitis (Sunburn-like)\" \/><span class=\"wpcf7-list-item-label\">Dermatitis (Sunburn-like)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"subsection required\">Immunotherapy <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-immunotherapy\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"\">The type(s) of immunotherapy <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-immunotherapy-type\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy-type[]\" value=\"ANK\" \/><span class=\"wpcf7-list-item-label\">ANK<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy-type[]\" value=\"DC (Dendritic Cells)\" \/><span class=\"wpcf7-list-item-label\">DC (Dendritic Cells)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy-type[]\" value=\"Activated Lymphocytes\" \/><span class=\"wpcf7-list-item-label\">Activated Lymphocytes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy-type[]\" value=\"Cancer Vaccine\" \/><span class=\"wpcf7-list-item-label\">Cancer Vaccine<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"\">Duration <\/span><span>From <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-immunotherapy-from\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length4\" min=\"1000\" max=\"9999\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"cancer-history-immunotherapy-from\" \/><\/span> <\/span><span>To <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-immunotherapy-to\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length4\" min=\"1000\" max=\"9999\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"cancer-history-immunotherapy-to\" \/><\/span> <\/span><br \/>\n<span class=\"\">Immune Checkpoint Inhabitors <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-immunotherapy-immunecheckpointinhabitors\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy-immunecheckpointinhabitors[]\" value=\"Opdivo\" \/><span class=\"wpcf7-list-item-label\">Opdivo<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy-immunecheckpointinhabitors[]\" value=\"Keytruda\" \/><span class=\"wpcf7-list-item-label\">Keytruda<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy-immunecheckpointinhabitors[]\" value=\"Yervoy\" \/><span class=\"wpcf7-list-item-label\">Yervoy<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy-immunecheckpointinhabitors[]\" value=\"Imfinzi\" \/><span class=\"wpcf7-list-item-label\">Imfinzi<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy-immunecheckpointinhabitors[]\" value=\"Tecentriq\" \/><span class=\"wpcf7-list-item-label\">Tecentriq<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy-immunecheckpointinhabitors[]\" value=\"Bavencio\" \/><span class=\"wpcf7-list-item-label\">Bavencio<\/span><\/label><\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"subsection required\">Current Cancer Medications <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-current-cancer-medications\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-current-cancer-medications\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-current-cancer-medications\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-current-cancer-medications-type\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-current-cancer-medications-type[]\" value=\"Cisplatin\" \/><span class=\"wpcf7-list-item-label\">Cisplatin<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-current-cancer-medications-type[]\" value=\"Doxorubicin\" \/><span class=\"wpcf7-list-item-label\">Doxorubicin<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-current-cancer-medications-type[]\" value=\"Trastuzumab (Herceptin)\" \/><span class=\"wpcf7-list-item-label\">Trastuzumab (Herceptin)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-current-cancer-medications-type[]\" value=\"Nivolumab (Opdivo)\" \/><span class=\"wpcf7-list-item-label\">Nivolumab (Opdivo)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-current-cancer-medications-type[]\" value=\"Tamoxifen\" \/><span class=\"wpcf7-list-item-label\">Tamoxifen<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-current-cancer-medications-type[]\" value=\"Lapatinib\" \/><span class=\"wpcf7-list-item-label\">Lapatinib<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-current-cancer-medications-type[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"subsection\">Other Medications <\/span><br \/>\n<span class=\"\">Please list the medications you're taking, including the name and dosage(amount of active ingredient e.g. mg).<\/span><br \/>\n<span class=\"required\">Blood thinners <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-blood-thinners\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-blood-thinners\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-blood-thinners\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-blood-thinners-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cancer-history-blood-thinners-text\" \/><\/span><\/span><br \/>\n<span class=\"required\">Blood thinning supplements <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-blood-thinning-supplements\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-blood-thinning-supplements\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-blood-thinning-supplements\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-blood-thinning-supplements-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cancer-history-blood-thinning-supplements-text\" \/><\/span> <\/span><br \/>\n<span class=\"required\">Hypertension <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-hypertension\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-hypertension\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-hypertension\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-hypertension-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cancer-history-hypertension-text\" \/><\/span><\/span><br \/>\n<span class=\"required\">Diabetes <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-diabetes\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-diabetes\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-diabetes\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-diabetes-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cancer-history-diabetes-text\" \/><\/span><\/span><br \/>\n<span class=\"required\">Dyslipidemia\/Cholesterol <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-dyslipidemia\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-dyslipidemia\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-dyslipidemia\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-dyslipidemia-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cancer-history-dyslipidemia-text\" \/><\/span><\/span><br \/>\n<span class=\"\">Other <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-other-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cancer-history-other-text\" \/><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"subsection required\">Data from Other Hospitals <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"data-from-other-hospitals\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"data-from-other-hospitals-items\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"Medical Certificate\" \/><span class=\"wpcf7-list-item-label\">Medical Certificate<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"Treatment Progress Record\" \/><span class=\"wpcf7-list-item-label\">Treatment Progress Record<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"Blood Test Results\" \/><span class=\"wpcf7-list-item-label\">Blood Test Results<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"X-ray\" \/><span class=\"wpcf7-list-item-label\">X-ray<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"CT Scan\" \/><span class=\"wpcf7-list-item-label\">CT Scan<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"MRI\" \/><span class=\"wpcf7-list-item-label\">MRI<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"PET Scan\" \/><span class=\"wpcf7-list-item-label\">PET Scan<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"Surgical Record\" \/><span class=\"wpcf7-list-item-label\">Surgical Record<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"Radiation Therapy Record\" \/><span class=\"wpcf7-list-item-label\">Radiation Therapy Record<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"Chemotherapy Record\" \/><span class=\"wpcf7-list-item-label\">Chemotherapy Record<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"\">If you have medical records from another hospital, please upload them here.<\/span><br \/>\n<span class=\"\">Attachment file\uff1a<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"data-from-other-hospitals-uploadfile\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".jpeg,.jpg,.png,.gif,.bmp,.pdf\" aria-invalid=\"false\" type=\"file\" name=\"data-from-other-hospitals-uploadfile\" \/><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"section required\">Metastasis<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-metastasis\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-metastasis\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-metastasis\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>Location <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-metastasis-location\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cancer-history-metastasis-location\" \/><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"section\">Pain Assessment <\/span><br \/>\n<span class=\"subsection required\">Location of Pain <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-painassessment-location\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-painassessment-location[]\" value=\"None\" \/><span class=\"wpcf7-list-item-label\">None<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-painassessment-location[]\" value=\"Chest\" \/><span class=\"wpcf7-list-item-label\">Chest<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-painassessment-location[]\" value=\"Abdomen\" \/><span class=\"wpcf7-list-item-label\">Abdomen<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-painassessment-location[]\" value=\"Back\" \/><span class=\"wpcf7-list-item-label\">Back<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-painassessment-location[]\" value=\"Joint\" \/><span class=\"wpcf7-list-item-label\">Joint<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-painassessment-location[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"subsection required\">On a scale of 1 to 10, how would you rate the pain in that area?<\/span><br \/>\n<span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-painassessment-scaleofpain\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"cancer-history-painassessment-scaleofpain\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10\">10<\/option><\/select><\/span><\/span><span>(1= No pain, 10 = Worst pain imaginable)<\/span><br \/>\n<span class=\"subsection\">Type of Pain <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-painassessment-typeofpain\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-painassessment-typeofpain[]\" value=\"Sharp\" \/><span class=\"wpcf7-list-item-label\">Sharp<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-painassessment-typeofpain[]\" value=\"Dull\" \/><span class=\"wpcf7-list-item-label\">Dull<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-painassessment-typeofpain[]\" value=\"Throbbing\" \/><span class=\"wpcf7-list-item-label\">Throbbing<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-painassessment-typeofpain[]\" value=\"Burning\" \/><span class=\"wpcf7-list-item-label\">Burning<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-painassessment-typeofpain[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"subsection\">Duration and Frequency <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-painassessment-frequency\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-painassessment-frequency[]\" value=\"Constantly\" \/><span class=\"wpcf7-list-item-label\">Constantly<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-painassessment-frequency[]\" value=\"From Time to Time\" \/><span class=\"wpcf7-list-item-label\">From Time to Time<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-painassessment-frequency[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"subsection required\">Any Relief Measures <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-painassessment-anyreliefmeasures\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-painassessment-anyreliefmeasures[]\" value=\"None\" \/><span class=\"wpcf7-list-item-label\">None<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-painassessment-anyreliefmeasures[]\" value=\"NSAIDS\" \/><span class=\"wpcf7-list-item-label\">NSAIDS<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-painassessment-anyreliefmeasures[]\" value=\"Paracetamol\" \/><span class=\"wpcf7-list-item-label\">Paracetamol<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-painassessment-anyreliefmeasures[]\" value=\"Narcotic\" \/><span class=\"wpcf7-list-item-label\">Narcotic<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-painassessment-anyreliefmeasures[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"part\">Social History<\/span><br \/>\n<span class=\"section required\">Alcohol <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"social-history-alcohol\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"social-history-alcohol\" value=\"Do not drink\" \/><span class=\"wpcf7-list-item-label\">Do not drink<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"social-history-alcohol\" value=\"Drink\" \/><span class=\"wpcf7-list-item-label\">Drink<\/span><\/label><\/span><\/span><\/span><\/span><span>( <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"social-history-alcohol-amount\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"social-history-alcohol-amount\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"1 cup of sake\">1 cup of sake<\/option><option value=\"1 large bottle of beer\">1 large bottle of beer<\/option><option value=\"2\/3 cup of shochu\/awamori\">2\/3 cup of shochu\/awamori<\/option><option value=\"1 double shot of whiskey\">1 double shot of whiskey<\/option><option value=\"1\/3 bottle of wine\">1\/3 bottle of wine<\/option><option value=\"Drink more than this amount\">Drink more than this amount<\/option><\/select><\/span><\/span><span> )<\/span><br \/>\n<span class=\"section required\">Tobacco <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"social-history-tobacco\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"social-history-tobacco\" value=\"Do not smoke\" \/><span class=\"wpcf7-list-item-label\">Do not smoke<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"social-history-tobacco\" value=\"Smoke\" \/><span class=\"wpcf7-list-item-label\">Smoke<\/span><\/label><\/span><\/span><\/span><\/span><span> (<\/span><span> <span class=\"wpcf7-form-control-wrap\" data-name=\"social-history-tobacco-amount\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length2\" min=\"0\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"social-history-tobacco-amount\" \/><\/span><\/span><span> cigarettes\/day )<\/span>\n\t<\/p>\n\t<p><span class=\"part\">Medical History<\/span><br \/>\n<span class=\"section required\">Past Medical History <\/span> (Please check any medical problems that you have had in the past)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"medical-history\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"None\" \/><span class=\"wpcf7-list-item-label\">None<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"Anemia\" \/><span class=\"wpcf7-list-item-label\">Anemia<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"Anxiety\" \/><span class=\"wpcf7-list-item-label\">Anxiety<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"Arthritis\" \/><span class=\"wpcf7-list-item-label\">Arthritis<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"Asthma\" \/><span class=\"wpcf7-list-item-label\">Asthma<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"Allergies\" \/><span class=\"wpcf7-list-item-label\">Allergies<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"Clotting disorder\" \/><span class=\"wpcf7-list-item-label\">Clotting disorder<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"Headaches\" \/><span class=\"wpcf7-list-item-label\">Headaches<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"Kidney disease\" \/><span class=\"wpcf7-list-item-label\">Kidney disease<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"Liver disease\" \/><span class=\"wpcf7-list-item-label\">Liver disease<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"Osteoporosis\" \/><span class=\"wpcf7-list-item-label\">Osteoporosis<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"Seizures\" \/><span class=\"wpcf7-list-item-label\">Seizures<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"Stroke\" \/><span class=\"wpcf7-list-item-label\">Stroke<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"HIV\/AIDS\" \/><span class=\"wpcf7-list-item-label\">HIV\/AIDS<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"Hypothuroidism\" \/><span class=\"wpcf7-list-item-label\">Hypothuroidism<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"Hypertension (high blood pressure)\" \/><span class=\"wpcf7-list-item-label\">Hypertension (high blood pressure)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"Hyperlipidemia (high cholesterol)\" \/><span class=\"wpcf7-list-item-label\">Hyperlipidemia (high cholesterol)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"Diabetes mellitus\" \/><span class=\"wpcf7-list-item-label\">Diabetes mellitus<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"Heart problem\" \/><span class=\"wpcf7-list-item-label\">Heart problem<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"Tuberculosis\" \/><span class=\"wpcf7-list-item-label\">Tuberculosis<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"Ulcers\" \/><span class=\"wpcf7-list-item-label\">Ulcers<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"section\">Allergies <\/span><br \/>\n<span class=\"subsection required\">Food <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-food\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"None\" \/><span class=\"wpcf7-list-item-label\">None<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"Kiwi\" \/><span class=\"wpcf7-list-item-label\">Kiwi<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"Banana\" \/><span class=\"wpcf7-list-item-label\">Banana<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"Avocado\" \/><span class=\"wpcf7-list-item-label\">Avocado<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"Papaya\" \/><span class=\"wpcf7-list-item-label\">Papaya<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"Mango\" \/><span class=\"wpcf7-list-item-label\">Mango<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"Melon\" \/><span class=\"wpcf7-list-item-label\">Melon<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"Fig\" \/><span class=\"wpcf7-list-item-label\">Fig<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"Cherry\" \/><span class=\"wpcf7-list-item-label\">Cherry<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"Egg\" \/><span class=\"wpcf7-list-item-label\">Egg<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"Soy\" \/><span class=\"wpcf7-list-item-label\">Soy<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"Wheat\" \/><span class=\"wpcf7-list-item-label\">Wheat<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"Peanuts\" \/><span class=\"wpcf7-list-item-label\">Peanuts<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"Blue fish (e.g., mackerel, sardine)\" \/><span class=\"wpcf7-list-item-label\">Blue fish (e.g., mackerel, sardine)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"indent10\">If you selected \"Other,\" please specify the food.<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-food-other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"allergies-food-other\" \/><\/span><\/span><br \/>\n<span class=\"\">Severity of Allergic Reaction <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-food-severity\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"allergies-food-severity\" value=\"Mild\" \/><span class=\"wpcf7-list-item-label\">Mild<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food-severity\" value=\"Moderate\" \/><span class=\"wpcf7-list-item-label\">Moderate<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-food-severity\" value=\"Severe\" \/><span class=\"wpcf7-list-item-label\">Severe<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"subsection required\">Medication <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-medication\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"allergies-medication[]\" value=\"None\" \/><span class=\"wpcf7-list-item-label\">None<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-medication[]\" value=\"Aspirin (e.g., Bufferin)\" \/><span class=\"wpcf7-list-item-label\">Aspirin (e.g., Bufferin)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-medication[]\" value=\"Ibuprofen (e.g., Brufen, Eve)\" \/><span class=\"wpcf7-list-item-label\">Ibuprofen (e.g., Brufen, Eve)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-medication[]\" value=\"Loxoprofen (e.g., Loxonin)\" \/><span class=\"wpcf7-list-item-label\">Loxoprofen (e.g., Loxonin)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-medication[]\" value=\"Anesthetics (e.g., Xylocaine)\" \/><span class=\"wpcf7-list-item-label\">Anesthetics (e.g., Xylocaine)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-medication[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"\">If you selected \"Other,\" please specify the medication. <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-medication-other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"allergies-medication-other\" \/><\/span><\/span><br \/>\n<span class=\"\">Severity of Allergic Reaction<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-medication-severity\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"allergies-medication-severity\" value=\"Mild\" \/><span class=\"wpcf7-list-item-label\">Mild<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-medication-severity\" value=\"Moderate\" \/><span class=\"wpcf7-list-item-label\">Moderate<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-medication-severity\" value=\"Severe\" \/><span class=\"wpcf7-list-item-label\">Severe<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"subsection required\">Antibiotics\/Antifungals <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-antibiotics\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"None\" \/><span class=\"wpcf7-list-item-label\">None<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"Penicillin antibiotics\" \/><span class=\"wpcf7-list-item-label\">Penicillin antibiotics<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"Cephalosporins (e.g., Cefzon)\" \/><span class=\"wpcf7-list-item-label\">Cephalosporins (e.g., Cefzon)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"Streptomycin\" \/><span class=\"wpcf7-list-item-label\">Streptomycin<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"Amikacin\" \/><span class=\"wpcf7-list-item-label\">Amikacin<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"Aminoglycosides (excluding streptomycin, amikacin)\" \/><span class=\"wpcf7-list-item-label\">Aminoglycosides (excluding streptomycin, amikacin)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"Amphotericin B\" \/><span class=\"wpcf7-list-item-label\">Amphotericin B<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span> <\/span><br \/>\n<span class=\"\">If you selected \"Other,\" please specify the medication. <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-antibiotics-other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"allergies-antibiotics-other\" \/><\/span><\/span><br \/>\n<span class=\"\">Severity of Allergic Reaction <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-antibiotics-severity\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"allergies-antibiotics-severity\" value=\"Mild\" \/><span class=\"wpcf7-list-item-label\">Mild<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-antibiotics-severity\" value=\"Moderate\" \/><span class=\"wpcf7-list-item-label\">Moderate<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-antibiotics-severity\" value=\"Severe\" \/><span class=\"wpcf7-list-item-label\">Severe<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"subsection required\">Other <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-other\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"allergies-other[]\" value=\"None\" \/><span class=\"wpcf7-list-item-label\">None<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-other[]\" value=\"Latex\" \/><span class=\"wpcf7-list-item-label\">Latex<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-other[]\" value=\"Alcohol\" \/><span class=\"wpcf7-list-item-label\">Alcohol<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-other[]\" value=\"Iodine\" \/><span class=\"wpcf7-list-item-label\">Iodine<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"\">Severity of Allergic Reaction <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-other-severity\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"allergies-other-severity\" value=\"Mild\" \/><span class=\"wpcf7-list-item-label\">Mild<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-other-severity\" value=\"Moderate\" \/><span class=\"wpcf7-list-item-label\">Moderate<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-other-severity\" value=\"Severe\" \/><span class=\"wpcf7-list-item-label\">Severe<\/span><\/label><\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"part\">Assessment of Daily Living Activities<\/span><br \/>\n<span class=\"section required\">Mobility <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"dailylivingcctivities-mobility\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"dailylivingcctivities-mobility\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"dailylivingcctivities-mobility\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/span><span>If no, please specify the type<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"dailylivingcctivities-mobility-no\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"dailylivingcctivities-mobility-no[]\" value=\"Walker\" \/><span class=\"wpcf7-list-item-label\">Walker<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"dailylivingcctivities-mobility-no[]\" value=\"Wheelchair\" \/><span class=\"wpcf7-list-item-label\">Wheelchair<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"dailylivingcctivities-mobility-no[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"section required\">Catheter Use <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"dailylivingcctivities-catheter\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"dailylivingcctivities-catheter\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"dailylivingcctivities-catheter\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/span><span>If yes, please specify the type<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"dailylivingcctivities-catheter-yes\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"dailylivingcctivities-catheter-yes[]\" value=\"Urinary Catheter\" \/><span class=\"wpcf7-list-item-label\">Urinary Catheter<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"dailylivingcctivities-catheter-yes[]\" value=\"Feeding Tube\" \/><span class=\"wpcf7-list-item-label\">Feeding Tube<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"dailylivingcctivities-catheter-yes[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"part\">Family History of Cancer<\/span><br \/>\n<span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-family-father\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"cancer-history-family-father[]\" value=\"Father\" \/><span class=\"wpcf7-list-item-label\">Father<\/span><\/label><\/span><\/span><\/span><\/span><span>Location <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-family-father-location\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cancer-history-family-father-location\" \/><\/span><\/span><br \/>\n<span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-family-mother\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"cancer-history-family-mother[]\" value=\"Mother\" \/><span class=\"wpcf7-list-item-label\">Mother<\/span><\/label><\/span><\/span><\/span><\/span><span>Location <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-family-mother-location\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cancer-history-family-mother-location\" \/><\/span><\/span><br \/>\n<span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-family-grandfather\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"cancer-history-family-grandfather[]\" value=\"Grandfather\" \/><span class=\"wpcf7-list-item-label\">Grandfather<\/span><\/label><\/span><\/span><\/span><\/span><span> Location<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-family-grandfather-location\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cancer-history-family-grandfather-location\" \/><\/span><\/span><br \/>\n<span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-family-grandmother\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"cancer-history-family-grandmother[]\" value=\"Grandmother\" \/><span class=\"wpcf7-list-item-label\">Grandmother<\/span><\/label><\/span><\/span><\/span><\/span><span>Location<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-family-grandmother-location\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cancer-history-family-grandmother-location\" \/><\/span><\/span><br \/>\n<span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-family-other\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"cancer-history-family-other[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span><\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-family-other-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cancer-history-family-other-text\" \/><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"chapter\">Emergency Contact<\/span><br \/>\n<span>Name<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-ec-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-ec-name\" \/><\/span><br \/>\n<span>Phone Number<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-ec-phone-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"your-ec-phone-number\" \/><\/span><br \/>\n<span>Email Address<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-ec-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-ec-email\" \/><\/span><br \/>\n<span>Relationship with Patient<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-ec-relationship\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-ec-relationship\" \/><\/span>\n\t<\/p>\n\t<p><span class=\"part\">Additional Notes <\/span><span>Please include any additional information that may be relevant to your overall health condition<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"additional-notes\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"additional-notes\"><\/textarea><\/span>\n\t<\/p>\n\t<p><span class=\"part\">Source Questions<\/span><br \/>\n<span class=\"section required\">Please select the purpose of your inquiry.<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"purpose-of-your-inquiry\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"purpose-of-your-inquiry[]\" value=\"Make an appointment\" \/><span class=\"wpcf7-list-item-label\">Make an appointment<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"purpose-of-your-inquiry[]\" value=\"Ask about consultation and treatment\" \/><span class=\"wpcf7-list-item-label\">Ask about consultation and treatment<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"purpose-of-your-inquiry[]\" value=\"Inquire about fees and payment\" \/><span class=\"wpcf7-list-item-label\">Inquire about fees and payment<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"purpose-of-your-inquiry[]\" value=\"Ask about other matters\" \/><span class=\"wpcf7-list-item-label\">Ask about other matters<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"purpose-of-your-inquiry[]\" value=\"Need immediate treatment\" \/><span class=\"wpcf7-list-item-label\">Need immediate treatment<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"section required\">How did you hear about our clinic?<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"how-about-our-clinic\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"how-about-our-clinic[]\" value=\"Friend&#039;s referral\" \/><span class=\"wpcf7-list-item-label\">Friend&#039;s referral<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"how-about-our-clinic[]\" value=\"Agent&#039;s referral\" \/><span class=\"wpcf7-list-item-label\">Agent&#039;s referral<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"how-about-our-clinic[]\" value=\"Attended seminar\" \/><span class=\"wpcf7-list-item-label\">Attended seminar<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"how-about-our-clinic[]\" value=\"Saw website\" \/><span class=\"wpcf7-list-item-label\">Saw website<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"how-about-our-clinic[]\" value=\"Instagram\" \/><span class=\"wpcf7-list-item-label\">Instagram<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"how-about-our-clinic[]\" value=\"Facebook\" \/><span class=\"wpcf7-list-item-label\">Facebook<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"how-about-our-clinic[]\" value=\"WeChat\" \/><span class=\"wpcf7-list-item-label\">WeChat<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"how-about-our-clinic[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span><br \/>\n<span>If you select other, please specify how you found out about the clinic, and It would be helpful if you could provide the name of friend or agent who referred you.<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"how-about-our-clinic-other\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"how-about-our-clinic-other\"><\/textarea><\/span><br \/>\nThank you very much for your cooperation.<br \/>\n<div class=\"cf7-cf-turnstile\" style=\"margin-top: 0px; margin-bottom: -15px;\"> <div id=\"cf-turnstile-cf7-3185917309\" class=\"cf-turnstile\" data-sitekey=\"0x4AAAAAABuDPzjTEgcGuVnP\" data-theme=\"auto\" data-language=\"auto\" data-size=\"normal\" data-retry=\"auto\" data-retry-interval=\"1000\" data-refresh-expired=\"auto\" data-action=\"contact-form-7\" data-appearance=\"always\"><\/div> <script>document.addEventListener(\"DOMContentLoaded\", function() { setTimeout(function(){ var e=document.getElementById(\"cf-turnstile-cf7-3185917309\"); e&&!e.innerHTML.trim()&&(turnstile.remove(\"#cf-turnstile-cf7-3185917309\"), turnstile.render(\"#cf-turnstile-cf7-3185917309\", {sitekey:\"0x4AAAAAABuDPzjTEgcGuVnP\"})); }, 100); });<\/script> <br class=\"cf-turnstile-br cf-turnstile-br-cf7-3185917309\"> <style>#cf-turnstile-cf7-3185917309 { margin-left: -15px; }<\/style> <script>document.addEventListener(\"DOMContentLoaded\",function(){document.querySelectorAll('.wpcf7-form').forEach(function(e){e.addEventListener('submit',function(){if(document.getElementById('cf-turnstile-cf7-3185917309')){setTimeout(function(){turnstile.reset('#cf-turnstile-cf7-3185917309');},1000)}})})});<\/script> <\/div><br\/><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n\t<\/p>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Cancer Treatment Questionnaire For those wishing to receive cancer treatment, please fill out and submit the questionnaire before your consultation. Sharing your information in advance will help shorten the consultation time and contribute to a more in-depth and productive session. \u203bDisclaimer: This form is used to collect information about patients and used for internal purposes [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-9787","page","type-page","status-publish","hentry","no-thumb"],"_links":{"self":[{"href":"https:\/\/mrclinic.tokyo\/en\/wp-json\/wp\/v2\/pages\/9787","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/mrclinic.tokyo\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/mrclinic.tokyo\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/mrclinic.tokyo\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/mrclinic.tokyo\/en\/wp-json\/wp\/v2\/comments?post=9787"}],"version-history":[{"count":12,"href":"https:\/\/mrclinic.tokyo\/en\/wp-json\/wp\/v2\/pages\/9787\/revisions"}],"predecessor-version":[{"id":10643,"href":"https:\/\/mrclinic.tokyo\/en\/wp-json\/wp\/v2\/pages\/9787\/revisions\/10643"}],"wp:attachment":[{"href":"https:\/\/mrclinic.tokyo\/en\/wp-json\/wp\/v2\/media?parent=9787"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}