{"id":101495,"date":"2026-05-10T19:30:39","date_gmt":"2026-05-10T19:30:39","guid":{"rendered":"https:\/\/balloutinemethod.com\/?page_id=101495"},"modified":"2026-05-23T20:16:48","modified_gmt":"2026-05-23T20:16:48","slug":"client_info","status":"publish","type":"page","link":"https:\/\/balloutinemethod.com\/en\/client_info\/","title":{"rendered":"Balloutine Method Client Questionnaire"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"101495\" class=\"elementor elementor-101495\">\n\t\t\t\t<div class=\"elementor-element elementor-element-230048b e-flex e-con-boxed e-con e-parent\" data-id=\"230048b\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-988054f elementor-widget elementor-widget-html\" data-id=\"988054f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t\t<style>#dfb-form-9 { --dfb-max-width: 680px; --dfb-bg-color: #f7f7f7; --dfb-text-color: #1f2937; --dfb-label-color: #6b7280; --dfb-input-bg: #f9fafb; --dfb-input-border: #e5e7eb; --dfb-primary-color: #8b5cf6; --dfb-btn-text: #ffffff; --dfb-btn-grad-start: #1488cc; --dfb-btn-grad-end: #1488cc; --dfb-font-size: 1rem; --dfb-label-size: 1.1rem; --dfb-label-weight: 600; --dfb-border-radius: 12px; --dfb-field-gap: 35px; --dfb-label-spacing: 10px; --dfb-input-padding: 14px 16px; --dfb-card-shadow: 0 12px 48px rgba(0,0,0,0.06); }\n.dfb-input-error { border-color: #ef4444 !important; box-shadow: 0 0 0 3px rgba(239, 68, 68, 0.1) !important; }\n<\/style><div class=\"dfb-form-wrapper\" id=\"dfb-form-9\" dir=\"ltr\" data-identity-locked=\"0\">\n\t<div class=\"dfb-form-heading\"><h2 class=\"dfb-form-title\">Balloutine Method Client Questionnaire<\/h2><\/div>\t<form class=\"dfb-form\" method=\"post\" action=\"\" novalidate=\"novalidate\" data-trp-original-action=\"\">\n\t\t<input type=\"hidden\" name=\"dfb_form_id\" value=\"9\">\n\t\t\t\t<input type=\"hidden\" id=\"dfb_nonce\" name=\"dfb_nonce\" value=\"92d3ba31b9\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/101495\" \/>\t\t\n\t\t\t\t\t\t\t\t\n\t\t\t<div class=\"dfb-field-group dfb-field-type-text\">\n\t\t\t\t\t\t\t\t\t<label for=\"dfb-field-9-text_606\" class=\"dfb-label\">\n\t\t\t\t\t\tFull Name\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"dfb-required\" aria-hidden=\"true\">*<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\n\t\t\t\t<div class=\"dfb-input-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t<input type=\"text\" name=\"text_606\" id=\"dfb-field-9-text_606\" class=\"dfb-input dfb-input-text\" placeholder=\"Example: Ahmed Mohammed\" value=\"\" required>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\n\t\t\t<div class=\"dfb-field-group dfb-field-type-email\">\n\t\t\t\t\t\t\t\t\t<label for=\"dfb-field-9-email_834\" class=\"dfb-label\">\n\t\t\t\t\t\tEmail Address\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\n\t\t\t\t<div class=\"dfb-input-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t<input type=\"email\" name=\"email_834\" id=\"dfb-field-9-email_834\" class=\"dfb-input dfb-input-email\" placeholder=\"example@domain.com\" value=\"\" >\n\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\n\t\t\t<div class=\"dfb-field-group dfb-field-type-whatsapp\">\n\t\t\t\t\t\t\t\t\t<label for=\"dfb-field-9-whatsapp_311\" class=\"dfb-label\">\n\t\t\t\t\t\tWhatsApp Number\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"dfb-required\" aria-hidden=\"true\">*<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\n\t\t\t\t<div class=\"dfb-input-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t<input type=\"tel\" name=\"whatsapp_311\" id=\"dfb-field-9-whatsapp_311\" class=\"dfb-input dfb-input-whatsapp\" placeholder=\"050 123 4567\" value=\"\" required>\n\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\n\t\t\t<div class=\"dfb-field-group dfb-field-type-text\">\n\t\t\t\t\t\t\t\t\t<label for=\"dfb-field-9-id_num\" class=\"dfb-label\">\n\t\t\t\t\t\tID Number\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\n\t\t\t\t<div class=\"dfb-input-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t<input type=\"text\" name=\"id_num\" id=\"dfb-field-9-id_num\" class=\"dfb-input dfb-input-text\"  value=\"\" >\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\n\t\t\t<div class=\"dfb-field-group dfb-field-type-dob\">\n\t\t\t\t\t\t\t\t\t<label for=\"dfb-field-9-dob\" class=\"dfb-label\">\n\t\t\t\t\t\tDate of Birth\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\n\t\t\t\t<div class=\"dfb-input-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"dfb-dob-group\" style=\"display:flex; gap:10px; width:100%;\">\n\t\t\t\t\t\t\t<select class=\"dfb-input dfb-input-dob  dfb-dob-day\" data-dob-target=\"#dfb-field-9-dob\"  style=\"flex:1; padding-left: 8px; padding-right: 8px;\">\n\t\t\t\t\t\t\t\t<option value=\"\">Day<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"01\" >1<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"02\" >2<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"03\" >3<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"04\" >4<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"05\" >5<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"06\" >6<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"07\" >7<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"08\" >8<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"09\" >9<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"10\" >10<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"11\" >11<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"12\" >12<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"13\" >13<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"14\" >14<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"15\" >15<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"16\" >16<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"17\" >17<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"18\" >18<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"19\" >19<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"20\" >20<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"21\" >21<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"22\" >22<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"23\" >23<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"24\" >24<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"25\" >25<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"26\" >26<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"27\" >27<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"28\" >28<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"29\" >29<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"30\" >30<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"31\" >31<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<select class=\"dfb-input dfb-input-dob  dfb-dob-month\" data-dob-target=\"#dfb-field-9-dob\"  style=\"flex:1; padding-left: 8px; padding-right: 8px;\">\n\t\t\t\t\t\t\t\t<option value=\"\">Month<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"01\" >Jan<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"02\" >Feb<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"03\" >Mar<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"04\" >Apr<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"05\" >May<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"06\" >Jun<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"07\" >Jul<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"08\" >Aug<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"09\" >Sep<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"10\" >Oct<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"11\" >Nov<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"12\" >Dec<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t\t<select class=\"dfb-input dfb-input-dob  dfb-dob-year\" data-dob-target=\"#dfb-field-9-dob\"  style=\"flex:1.2; padding-left: 8px; padding-right: 8px;\">\n\t\t\t\t\t\t\t\t<option value=\"\">Year<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2026\" >2026<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2025\" >2025<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2024\" >2024<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2023\" >2023<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2022\" >2022<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2021\" >2021<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2020\" >2020<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2019\" >2019<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2018\" >2018<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2017\" >2017<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2016\" >2016<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2015\" >2015<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2014\" >2014<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2013\" >2013<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2012\" >2012<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2011\" >2011<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2010\" >2010<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2009\" >2009<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2008\" >2008<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2007\" >2007<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2006\" >2006<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2005\" >2005<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2004\" >2004<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2003\" >2003<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2002\" >2002<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2001\" >2001<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"2000\" >2000<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1999\" >1999<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1998\" >1998<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1997\" >1997<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1996\" >1996<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1995\" >1995<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1994\" >1994<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1993\" >1993<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1992\" >1992<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1991\" >1991<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1990\" >1990<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1989\" >1989<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1988\" >1988<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1987\" >1987<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1986\" >1986<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1985\" >1985<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1984\" >1984<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1983\" >1983<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1982\" >1982<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1981\" >1981<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1980\" >1980<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1979\" >1979<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1978\" >1978<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1977\" >1977<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1976\" >1976<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1975\" >1975<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1974\" >1974<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1973\" >1973<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1972\" >1972<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1971\" >1971<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1970\" >1970<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1969\" >1969<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1968\" >1968<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1967\" >1967<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1966\" >1966<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1965\" >1965<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1964\" >1964<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1963\" >1963<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1962\" >1962<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1961\" >1961<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1960\" >1960<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1959\" >1959<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1958\" >1958<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1957\" >1957<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1956\" >1956<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1955\" >1955<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1954\" >1954<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1953\" >1953<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1952\" >1952<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1951\" >1951<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1950\" >1950<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1949\" >1949<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1948\" >1948<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1947\" >1947<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1946\" >1946<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1945\" >1945<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1944\" >1944<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1943\" >1943<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1942\" >1942<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1941\" >1941<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1940\" >1940<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1939\" >1939<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1938\" >1938<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1937\" >1937<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1936\" >1936<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1935\" >1935<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1934\" >1934<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1933\" >1933<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1932\" >1932<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1931\" >1931<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1930\" >1930<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1929\" >1929<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1928\" >1928<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1927\" >1927<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option value=\"1926\" >1926<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<input type=\"hidden\" name=\"dob\" id=\"dfb-field-9-dob\" class=\"dfb-dob-hidden\" value=\"\" >\n\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\n\t\t\t<div class=\"dfb-field-group dfb-field-type-textarea\">\n\t\t\t\t\t\t\t\t\t<label for=\"dfb-field-9-medication\" class=\"dfb-label\">\n\t\t\t\t\t\tWhat pain or problem are you experiencing?\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\n\t\t\t\t<div class=\"dfb-input-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t<textarea name=\"medication\" id=\"dfb-field-9-medication\" class=\"dfb-input dfb-input-textarea\" placeholder=\"Describe the location of the pain and any related symptoms. Example: lower-back pain for two weeks, worse when sitting and extending into the leg.\" ><\/textarea>\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\n\t\t\t<div class=\"dfb-field-group dfb-field-type-textarea\">\n\t\t\t\t\t\t\t\t\t<label for=\"dfb-field-9-time_of_pain\" class=\"dfb-label\">\n\t\t\t\t\t\tWhen did the pain or problem begin?\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\n\t\t\t\t<div class=\"dfb-input-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t<textarea name=\"time_of_pain\" id=\"dfb-field-9-time_of_pain\" class=\"dfb-input dfb-input-textarea\"  ><\/textarea>\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\n\t\t\t<div class=\"dfb-field-group dfb-field-type-radio\">\n\t\t\t\t\t\t\t\t\t<label for=\"dfb-field-9-pain_desc\" class=\"dfb-label\">\n\t\t\t\t\t\tIs the pain:\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\n\t\t\t\t<div class=\"dfb-input-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"dfb-radio-group\">\n\t\t\t\t\t\t\t<label class=\"dfb-radio-label\"><input type=\"radio\" name=\"pain_desc\" id=\"dfb-field-9-pain_desc-0\" value=\"\u0645\u0633\u062a\u0645\u0631\" class=\"dfb-input dfb-input-radio\"  > Constant<\/label><label class=\"dfb-radio-label\"><input type=\"radio\" name=\"pain_desc\" id=\"dfb-field-9-pain_desc-1\" value=\"\u0645\u062a\u0642\u0637\u0639\" class=\"dfb-input dfb-input-radio\"  > Intermittent<\/label>\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\n\t\t\t<div class=\"dfb-field-group dfb-field-type-text\">\n\t\t\t\t\t\t\t\t\t<label for=\"dfb-field-9-pain_place\" class=\"dfb-label\">\n\t\t\t\t\t\tLocation of Pain\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\n\t\t\t\t<div class=\"dfb-input-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t<input type=\"text\" name=\"pain_place\" id=\"dfb-field-9-pain_place\" class=\"dfb-input dfb-input-text\"  value=\"\" >\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\n\t\t\t<div class=\"dfb-field-group dfb-field-type-checkbox\">\n\t\t\t\t\t\t\t\t\t<label for=\"dfb-field-9-pain_value\" class=\"dfb-label\">\n\t\t\t\t\t\tPain Intensity (1\u201310)\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\n\t\t\t\t<div class=\"dfb-input-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"dfb-checkbox-group\">\n\t\t\t\t\t\t\t<label class=\"dfb-checkbox-label\"><input type=\"checkbox\" name=\"pain_value[]\" id=\"dfb-field-9-pain_value-0\" value=\"1\" class=\"dfb-input dfb-input-checkbox\" > 1<\/label><label class=\"dfb-checkbox-label\"><input type=\"checkbox\" name=\"pain_value[]\" id=\"dfb-field-9-pain_value-1\" value=\"2\" class=\"dfb-input dfb-input-checkbox\" > 2<\/label><label class=\"dfb-checkbox-label\"><input type=\"checkbox\" name=\"pain_value[]\" id=\"dfb-field-9-pain_value-2\" value=\"3\" class=\"dfb-input dfb-input-checkbox\" > 3<\/label><label class=\"dfb-checkbox-label\"><input type=\"checkbox\" name=\"pain_value[]\" id=\"dfb-field-9-pain_value-3\" value=\"4\" class=\"dfb-input dfb-input-checkbox\" > 4<\/label><label class=\"dfb-checkbox-label\"><input type=\"checkbox\" name=\"pain_value[]\" id=\"dfb-field-9-pain_value-4\" value=\"5\" class=\"dfb-input dfb-input-checkbox\" > 5<\/label><label class=\"dfb-checkbox-label\"><input type=\"checkbox\" name=\"pain_value[]\" id=\"dfb-field-9-pain_value-5\" value=\"6\" class=\"dfb-input dfb-input-checkbox\" > 6<\/label><label class=\"dfb-checkbox-label\"><input type=\"checkbox\" name=\"pain_value[]\" id=\"dfb-field-9-pain_value-6\" value=\"7\" class=\"dfb-input dfb-input-checkbox\" > 7<\/label><label class=\"dfb-checkbox-label\"><input type=\"checkbox\" name=\"pain_value[]\" id=\"dfb-field-9-pain_value-7\" value=\"8\" class=\"dfb-input dfb-input-checkbox\" > 8<\/label><label class=\"dfb-checkbox-label\"><input type=\"checkbox\" name=\"pain_value[]\" id=\"dfb-field-9-pain_value-8\" value=\"9\" class=\"dfb-input dfb-input-checkbox\" > 9<\/label><label class=\"dfb-checkbox-label\"><input type=\"checkbox\" name=\"pain_value[]\" id=\"dfb-field-9-pain_value-9\" value=\"10\" class=\"dfb-input dfb-input-checkbox\" > 10<\/label>\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\n\t\t\t<div class=\"dfb-field-group dfb-field-type-checkbox\">\n\t\t\t\t\t\t\t\t\t<label for=\"dfb-field-9-pain_in_leg\" class=\"dfb-label\">\n\t\t\t\t\t\tDo you experience numbness in your legs?\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\n\t\t\t\t<div class=\"dfb-input-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"dfb-checkbox-group\">\n\t\t\t\t\t\t\t<label class=\"dfb-checkbox-label\"><input type=\"checkbox\" name=\"pain_in_leg[]\" id=\"dfb-field-9-pain_in_leg-0\" value=\"\u0646\u0639\u0645\" class=\"dfb-input dfb-input-checkbox\" > Yes<\/label><label class=\"dfb-checkbox-label\"><input type=\"checkbox\" name=\"pain_in_leg[]\" id=\"dfb-field-9-pain_in_leg-1\" value=\"\u0644\u0627\" class=\"dfb-input dfb-input-checkbox\" > No<\/label><label class=\"dfb-checkbox-label\"><input type=\"checkbox\" name=\"pain_in_leg[]\" id=\"dfb-field-9-pain_in_leg-2\" value=\"\u0639\u0646\u062f \u0627\u0644\u0645\u0634\u064a\" class=\"dfb-input dfb-input-checkbox\" > While Walking<\/label><label class=\"dfb-checkbox-label\"><input type=\"checkbox\" name=\"pain_in_leg[]\" id=\"dfb-field-9-pain_in_leg-3\" value=\"\u0639\u0646\u062f \u0627\u0644\u062c\u0644\u0648\u0633\" class=\"dfb-input dfb-input-checkbox\" > While Sitting<\/label><label class=\"dfb-checkbox-label\"><input type=\"checkbox\" name=\"pain_in_leg[]\" id=\"dfb-field-9-pain_in_leg-4\" value=\"\u0623\u062b\u0646\u0627\u0621 \u0627\u0644\u0646\u0648\u0645\" class=\"dfb-input dfb-input-checkbox\" > During Sleep<\/label><label class=\"dfb-checkbox-label\"><input type=\"checkbox\" name=\"pain_in_leg[]\" id=\"dfb-field-9-pain_in_leg-5\" value=\"\u0639\u0646\u062f \u0627\u0644\u0648\u0642\u0648\u0641\" class=\"dfb-input dfb-input-checkbox\" > While Standing<\/label>\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\n\t\t\t<div class=\"dfb-field-group dfb-field-type-radio\">\n\t\t\t\t\t\t\t\t\t<label for=\"dfb-field-9-ct_mri\" class=\"dfb-label\">\n\t\t\t\t\t\tHave you had any medical imaging (MRI \/ CT \/ X-ray)?\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\n\t\t\t\t<div class=\"dfb-input-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"dfb-radio-group\">\n\t\t\t\t\t\t\t<label class=\"dfb-radio-label\"><input type=\"radio\" name=\"ct_mri\" id=\"dfb-field-9-ct_mri-0\" value=\"\u0646\u0639\u0645\" class=\"dfb-input dfb-input-radio\"  > Yes<\/label><label class=\"dfb-radio-label\"><input type=\"radio\" name=\"ct_mri\" id=\"dfb-field-9-ct_mri-1\" value=\"\u0644\u0627\" class=\"dfb-input dfb-input-radio\"  > No<\/label>\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\n\t\t\t<div class=\"dfb-field-group dfb-field-type-textarea\">\n\t\t\t\t\t\t\t\t\t<label for=\"dfb-field-9-ct_mri_desc\" class=\"dfb-label\">\n\t\t\t\t\t\tIf yes, what were the findings?\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\n\t\t\t\t<div class=\"dfb-input-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t<textarea name=\"ct_mri_desc\" id=\"dfb-field-9-ct_mri_desc\" class=\"dfb-input dfb-input-textarea\"  ><\/textarea>\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\n\t\t\t<div class=\"dfb-field-group dfb-field-type-radio\">\n\t\t\t\t\t\t\t\t\t<label for=\"dfb-field-9-past_medical\" class=\"dfb-label\">\n\t\t\t\t\t\tHave you received previous treatment for the same problem?\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\n\t\t\t\t<div class=\"dfb-input-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"dfb-radio-group\">\n\t\t\t\t\t\t\t<label class=\"dfb-radio-label\"><input type=\"radio\" name=\"past_medical\" id=\"dfb-field-9-past_medical-0\" value=\"\u0646\u0639\u0645\" class=\"dfb-input dfb-input-radio\"  > Yes<\/label><label class=\"dfb-radio-label\"><input type=\"radio\" name=\"past_medical\" id=\"dfb-field-9-past_medical-1\" value=\"\u0644\u0627\" class=\"dfb-input dfb-input-radio\"  > No<\/label>\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\n\t\t\t<div class=\"dfb-field-group dfb-field-type-textarea\">\n\t\t\t\t\t\t\t\t\t<label for=\"dfb-field-9-past_medical_desc\" class=\"dfb-label\">\n\t\t\t\t\t\tIf yes, what treatment did you receive?\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\n\t\t\t\t<div class=\"dfb-input-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t<textarea name=\"past_medical_desc\" id=\"dfb-field-9-past_medical_desc\" class=\"dfb-input dfb-input-textarea\"  ><\/textarea>\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\n\t\t\t<div class=\"dfb-field-group dfb-field-type-radio\">\n\t\t\t\t\t\t\t\t\t<label for=\"dfb-field-9-medicine_past\" class=\"dfb-label\">\n\t\t\t\t\t\tHave you received injections or taken medication for this problem?\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\n\t\t\t\t<div class=\"dfb-input-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"dfb-radio-group\">\n\t\t\t\t\t\t\t<label class=\"dfb-radio-label\"><input type=\"radio\" name=\"medicine_past\" id=\"dfb-field-9-medicine_past-0\" value=\"\u0646\u0639\u0645\" class=\"dfb-input dfb-input-radio\"  > Yes<\/label><label class=\"dfb-radio-label\"><input type=\"radio\" name=\"medicine_past\" id=\"dfb-field-9-medicine_past-1\" value=\"\u0644\u0627\" class=\"dfb-input dfb-input-radio\"  > No<\/label>\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\n\t\t\t<div class=\"dfb-field-group dfb-field-type-textarea\">\n\t\t\t\t\t\t\t\t\t<label for=\"dfb-field-9-medicine_past_desc\" class=\"dfb-label\">\n\t\t\t\t\t\tIf yes, please list them:\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\n\t\t\t\t<div class=\"dfb-input-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t<textarea name=\"medicine_past_desc\" id=\"dfb-field-9-medicine_past_desc\" class=\"dfb-input dfb-input-textarea\"  ><\/textarea>\n\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\n\t\t\t<div class=\"dfb-field-group dfb-field-type-radio\">\n\t\t\t\t\t\t\t\t\t<label for=\"dfb-field-9-accident_past\" class=\"dfb-label\">\n\t\t\t\t\t\tHave you had a previous fall or accident?\t\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\n\t\t\t\t<div class=\"dfb-input-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"dfb-radio-group\">\n\t\t\t\t\t\t\t<label class=\"dfb-radio-label\"><input type=\"radio\" name=\"accident_past\" id=\"dfb-field-9-accident_past-0\" value=\"\u0646\u0639\u0645\" class=\"dfb-input dfb-input-radio\"  > Yes<\/label><label class=\"dfb-radio-label\"><input type=\"radio\" name=\"accident_past\" id=\"dfb-field-9-accident_past-1\" value=\"\u0644\u0627\" class=\"dfb-input dfb-input-radio\"  > No<\/label>\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\n\t\t\t<div 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