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vision<\\\/b><\\\/div>  <div style=\\\"flex: 1 1 50%;\\\"><b>\\u00b7      Bowel\\\/bladder problems<\\\/b><\\\/div>  <div style=\\\"flex: 1 1 50%;\\\"><b>\\u00b7      Swallowing problems<\\\/b><\\\/div>  <div style=\\\"flex: 1 1 50%;\\\"><b>\\u00b7      Reduced or altered sensation in your groin, genitals or back passage area<\\\/b><\\\/div>  <div style=\\\"flex: 1 1 50%;\\\"><b>\\u00b7      Speech impairment<\\\/b><\\\/div>  <div style=\\\"flex: 1 1 50%;\\\"><b>\\u00b7      Weakness in both legs<\\\/b><\\\/div>  <div style=\\\"flex: 1 1 50%;\\\"><b>\\u00b7      History of cancer<\\\/b><\\\/div>  <div style=\\\"flex: 1 1 50%;\\\"><b>\\u00b7      Unexplained weight loss<\\\/b><\\\/div>  <div style=\\\"flex: 1 1 50%;\\\"><b>\\u00b7      Fainting<\\\/b><\\\/div>  <div style=\\\"flex: 1 1 50%;\\\"><\\\/div><\\\/div><p><\\\/p><p><\\\/p><h3 style=\\\"text-align: center; \\\"><b style=\\\"font-size: 1.3em;\\\">Information and Instructions<\\\/b><\\\/h3><o:p><\\\/o:p><p><\\\/p><p class=\\\"MsoNormal\\\">1.&nbsp;&nbsp;&nbsp;&nbsp;This form is to request a&nbsp;<b>ROUTINE<\\\/b>&nbsp;out-patients physiotherapy appointment only.<o:p><\\\/o:p><\\\/p><p class=\\\"MsoNormal\\\">If you consider your problem to be urgent you must get a referral from your GP.&nbsp;<o:p><\\\/o:p><\\\/p><p class=\\\"MsoNormal\\\">2.&nbsp;&nbsp;&nbsp;&nbsp;We can only accept referrals from patients who are registered with a GP Practice in&nbsp;<b>Edinburgh<\\\/b><o:p><\\\/o:p><\\\/p><p class=\\\"MsoNormal\\\">(If you are unsure please ask your GP practice)&nbsp;<o:p><\\\/o:p><\\\/p><p class=\\\"MsoNormal\\\">3.&nbsp;&nbsp;&nbsp;&nbsp;You must be aged 16 or over to use the self referral service&nbsp;<o:p><\\\/o:p><\\\/p><p class=\\\"MsoNormal\\\">4.&nbsp;&nbsp;&nbsp;&nbsp;Please refer yourself for&nbsp;<b>ONE<\\\/b>&nbsp;problem only<o:p><\\\/o:p><\\\/p><p class=\\\"MsoNormal\\\">(We are not able to accept self referral for multiple,unrelated problems - please ask your GP)<o:p><\\\/o:p><\\\/p><p class=\\\"MsoNormal\\\">5.&nbsp;&nbsp;&nbsp;&nbsp;We will inform your GP that you have attended physiotherapy<b>&nbsp;<\\\/b><\\\/p><p class=\\\"MsoNormal\\\"><b>Home visits&nbsp;<\\\/b>can only be arranged by your GP&nbsp;<o:p><\\\/o:p><\\\/p><p class=\\\"MsoNormal\\\"><b>Continence problems and walking aids:&nbsp;<\\\/b>  <a href=\\\"https:\\\/\\\/services.nhslothian.scot\\\/ecps\\\/self-referral\\\/\\\" target=\\\"_blank\\\">Please use the separate referral forms which can be found on our self-referral page<\\\/a>    <\\\/p><p class=\\\"MsoNormal\\\"><\\\/p><p class=\\\"MsoNormal\\\"><b>Equipment such as collars, wrist splints, knee braces,maternity belts etc<\\\/b>&nbsp;cannot be routinely provided.&nbsp;<o:p><\\\/o:p><\\\/p><p><\\\/p>\",\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"\",\"key\":\"html\",\"drawerDisabled\":false,\"manual_key\":true,\"id\":67,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"<p><a href=\\\"https:\\\/\\\/www.nhsinform.scot\\\/\\\" target=\\\"_blank\\\" style=\\\"background-color: rgb(249, 249, 249); font-family: sans-serif;\\\"><b>Click here for information, advice and exercise<\\\/b><\\\/a><\\\/p><p class=\\\"MsoNormal\\\" style=\\\"text-align: left;\\\"><b>If your problem is urgent, severe, or getting worse,contact your GP or NHS24&nbsp;&nbsp;(Phone 111)<\\\/b><\\\/p><p class=\\\"MsoNormal\\\" style=\\\"text-align: left;\\\">If you have any of the symptoms listed below, since this problem started, then you must consult your GP:<\\\/p><p><\\\/p><div style=\\\"display: flex; flex-wrap: wrap; gap: 1rem;\\\">  <div style=\\\"flex: 1 1 50%;\\\"><b>\\u00b7      Blurred vision<\\\/b><\\\/div>  <div style=\\\"flex: 1 1 50%;\\\"><b>\\u00b7      Bowel\\\/bladder problems<\\\/b><\\\/div>  <div style=\\\"flex: 1 1 50%;\\\"><b>\\u00b7      Swallowing problems<\\\/b><\\\/div>  <div style=\\\"flex: 1 1 50%;\\\"><b>\\u00b7      Reduced or altered sensation in your groin, genitals or back passage area<\\\/b><\\\/div>  <div style=\\\"flex: 1 1 50%;\\\"><b>\\u00b7      Speech impairment<\\\/b><\\\/div>  <div style=\\\"flex: 1 1 50%;\\\"><b>\\u00b7      Weakness in both legs<\\\/b><\\\/div>  <div style=\\\"flex: 1 1 50%;\\\"><b>\\u00b7      History of cancer<\\\/b><\\\/div>  <div style=\\\"flex: 1 1 50%;\\\"><b>\\u00b7      Unexplained weight loss<\\\/b><\\\/div>  <div style=\\\"flex: 1 1 50%;\\\"><b>\\u00b7      Fainting<\\\/b><\\\/div>  <div style=\\\"flex: 1 1 50%;\\\"><\\\/div><\\\/div><p><\\\/p><p><\\\/p><h3 style=\\\"text-align: center; \\\"><b style=\\\"font-size: 1.3em;\\\">Information and Instructions<\\\/b><\\\/h3><o:p><\\\/o:p><p><\\\/p><p class=\\\"MsoNormal\\\">1.&nbsp;&nbsp;&nbsp;&nbsp;This form is to request a&nbsp;<b>ROUTINE<\\\/b>&nbsp;out-patients physiotherapy appointment only.<o:p><\\\/o:p><\\\/p><p class=\\\"MsoNormal\\\">If you consider your problem to be urgent you must get a referral from your GP.&nbsp;<o:p><\\\/o:p><\\\/p><p class=\\\"MsoNormal\\\">2.&nbsp;&nbsp;&nbsp;&nbsp;We can only accept referrals from patients who are registered with a GP Practice in&nbsp;<b>Edinburgh<\\\/b><o:p><\\\/o:p><\\\/p><p class=\\\"MsoNormal\\\">(If you are unsure please ask your GP practice)&nbsp;<o:p><\\\/o:p><\\\/p><p class=\\\"MsoNormal\\\">3.&nbsp;&nbsp;&nbsp;&nbsp;You must be aged 16 or over to use the self referral service&nbsp;<o:p><\\\/o:p><\\\/p><p class=\\\"MsoNormal\\\">4.&nbsp;&nbsp;&nbsp;&nbsp;Please refer yourself for&nbsp;<b>ONE<\\\/b>&nbsp;problem only<o:p><\\\/o:p><\\\/p><p class=\\\"MsoNormal\\\">(We are not able to accept self referral for multiple,unrelated problems - please ask your GP)<o:p><\\\/o:p><\\\/p><p class=\\\"MsoNormal\\\">5.&nbsp;&nbsp;&nbsp;&nbsp;We will inform your GP that you have attended physiotherapy<b>&nbsp;<\\\/b><\\\/p><p class=\\\"MsoNormal\\\"><b>Home visits&nbsp;<\\\/b>can only be arranged by your GP&nbsp;<o:p><\\\/o:p><\\\/p><p class=\\\"MsoNormal\\\"><b>Continence problems and walking aids:&nbsp;<\\\/b>  <a href=\\\"https:\\\/\\\/services.nhslothian.scot\\\/ecps\\\/self-referral\\\/\\\" target=\\\"_blank\\\">Please use the separate referral forms which can be found on our self-referral page<\\\/a>    <\\\/p><p class=\\\"MsoNormal\\\"><\\\/p><p class=\\\"MsoNormal\\\"><b>Equipment such as collars, wrist splints, knee braces,maternity belts etc<\\\/b>&nbsp;cannot be routinely provided.&nbsp;<o:p><\\\/o:p><\\\/p><p><\\\/p>\",\"label_pos\":\"above\",\"parentType\":\"html\",\"element_templates\":[\"html\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":3,\"idAttribute\":\"id\",\"type\":\"checkbox\",\"label\":\"I can confirm that I understand the above\",\"key\":\"confirm_you_are_happy_to_continue_1764061551509\",\"label_pos\":\"right\",\"required\":1,\"container_class\":\"\",\"element_class\":\"\",\"manual_key\":true,\"admin_label\":\"\",\"help_text\":\"<p>You must 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left\",\"manual_key\":false,\"admin_label\":\"\",\"help_text\":\"\",\"mask\":\"\",\"custom_mask\":\"99999999999\",\"custom_name_attribute\":\"phone\",\"personally_identifiable\":1,\"value\":\"\",\"drawerDisabled\":false,\"id\":37,\"beforeField\":\"\",\"afterField\":\"\",\"parentType\":\"textbox\",\"element_templates\":[\"tel\",\"textbox\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":15,\"idAttribute\":\"id\",\"type\":\"phone\",\"label\":\"Mobile Phone\",\"key\":\"mobile_phone_1749200930533\",\"label_pos\":\"above\",\"required\":1,\"default\":\"\",\"placeholder\":\"\",\"container_class\":\"one-half\",\"element_class\":\"\",\"input_limit\":\"\",\"input_limit_type\":\"characters\",\"input_limit_msg\":\"Character(s) left\",\"manual_key\":false,\"admin_label\":\"\",\"help_text\":\"<p>Please give a daytime number - we may contact you either by phone or post.<\\\/p>\",\"mask\":\"\",\"custom_mask\":\"99999999999\",\"custom_name_attribute\":\"phone\",\"personally_identifiable\":1,\"value\":\"\",\"drawerDisabled\":false,\"id\":38,\"beforeField\":\"\",\"afterField\":\"\",\"parentType\":\"textbox\",\"element_templates\":[\"tel\",\"textbox\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":16,\"idAttribute\":\"id\",\"type\":\"listradio\",\"label\":\"Can we leave a voice message?\",\"key\":\"can_we_leave_a_voice_message_1749201259527\",\"label_pos\":\"above\",\"required\":1,\"options\":[{\"errors\":[],\"max_options\":0,\"label\":\"Yes\",\"value\":\"Yes\",\"calc\":\"\",\"selected\":1,\"order\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"No\",\"value\":\"No\",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true}],\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"drawerDisabled\":false,\"id\":39,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"parentType\":\"list\",\"element_templates\":[\"listradio\",\"input\"],\"old_classname\":\"list-radio\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":17,\"idAttribute\":\"id\",\"type\":\"textbox\",\"label\":\"GP Practice\",\"key\":\"gp_practice_1749202438007\",\"label_pos\":\"above\",\"required\":1,\"default\":\"\",\"placeholder\":\"\",\"container_class\":\"\",\"element_class\":\"\",\"input_limit\":\"\",\"input_limit_type\":\"characters\",\"input_limit_msg\":\"Character(s) left\",\"manual_key\":false,\"admin_label\":\"\",\"help_text\":\"\",\"mask\":\"\",\"custom_mask\":\"\",\"custom_name_attribute\":\"\",\"personally_identifiable\":\"\",\"value\":\"\",\"drawerDisabled\":false,\"id\":40,\"beforeField\":\"\",\"afterField\":\"\",\"parentType\":\"textbox\",\"element_templates\":[\"textbox\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":18,\"idAttribute\":\"id\",\"type\":\"listradio\",\"label\":\"Is you GP aware of the problem?\",\"key\":\"is_you_gp_aware_of_the_problem_1749202489952\",\"label_pos\":\"above\",\"required\":1,\"options\":[{\"errors\":[],\"max_options\":0,\"label\":\"Yes\",\"value\":\"Yes\",\"calc\":\"\",\"selected\":1,\"order\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"No\",\"value\":\"No\",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true}],\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"drawerDisabled\":false,\"id\":41,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"parentType\":\"list\",\"element_templates\":[\"listradio\",\"input\"],\"old_classname\":\"list-radio\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":19,\"idAttribute\":\"id\",\"type\":\"listradio\",\"label\":\"Who advised you self refer? \",\"key\":\"who_advised_you_self_refer_1750949187720\",\"label_pos\":\"above\",\"required\":1,\"options\":[{\"errors\":[],\"max_options\":0,\"label\":\"GP\",\"value\":\"GP\",\"calc\":\"\",\"selected\":0,\"order\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"Other Healthcare professional\",\"value\":\"Other Healthcare professional\",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":2,\"new\":false,\"options\":[],\"label\":\"None \\\/ Myself\",\"value\":\"None Myself\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true}],\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"\",\"help_text\":\"Please select the most appropriate\",\"drawerDisabled\":false,\"id\":60,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"parentType\":\"list\",\"element_templates\":[\"listradio\",\"input\"],\"old_classname\":\"list-radio\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":20,\"idAttribute\":\"id\",\"type\":\"hr\",\"label\":\"Divider Copy\",\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"\",\"key\":\"hr_1749202625109\",\"drawerDisabled\":false,\"id\":42,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"label_pos\":\"above\",\"parentType\":\"hr\",\"element_templates\":[\"hr\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":21,\"idAttribute\":\"id\",\"type\":\"html\",\"label\":\"When answering the questions below, please check the box that applies to you best:\",\"default\":\"<h4>When answering the questions below, please check the box that applies to you best:<\\\/h4>\",\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"\",\"key\":\"when_answering_the_questions_below_please_check_the_box_that_applies_to_you_best_1764003501920\",\"drawerDisabled\":false,\"id\":43,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"<h4>When answering the questions below, please check the box that applies to you best:<\\\/h4>\",\"label_pos\":\"above\",\"parentType\":\"html\",\"element_templates\":[\"html\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":22,\"idAttribute\":\"id\",\"type\":\"listradio\",\"label\":\"Where is the main problem area?\",\"key\":\"where_is_the_main_problem_area_1749202647014\",\"label_pos\":\"above\",\"required\":1,\"options\":[{\"errors\":[],\"max_options\":0,\"label\":\"Neck\",\"value\":\"Neck\",\"calc\":\"\",\"selected\":0,\"order\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"Neck with arm pain\",\"value\":\"Neck with arm pain\",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"Shoulder\",\"value\":\"Shoulder\",\"calc\":\"\",\"selected\":0,\"order\":2,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":3,\"new\":false,\"options\":[],\"label\":\"Elbow\",\"value\":\"Elbow\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":4,\"new\":false,\"options\":[],\"label\":\"Wrist\\\/Hand\",\"value\":\"Wrist-Hand\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":5,\"new\":false,\"options\":[],\"label\":\"Lower Back\",\"value\":\"Lower Back\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":6,\"new\":false,\"options\":[],\"label\":\"Lower back with leg pain\",\"value\":\"Lower back with leg pain\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons 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