{"id":109,"date":"2023-03-23T23:44:01","date_gmt":"2023-03-23T23:44:01","guid":{"rendered":"https:\/\/caspianclients.com\/survey\/?page_id=109"},"modified":"2023-03-29T23:01:37","modified_gmt":"2023-03-29T23:01:37","slug":"form","status":"publish","type":"page","link":"https:\/\/caspianclients.com\/survey\/form\/","title":{"rendered":"Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"109\" class=\"elementor elementor-109\">\n\t\t\t\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-80dffa6 elementor-section-full_width elementor-section-stretched elementor-section-height-default elementor-section-height-default\" data-id=\"80dffa6\" data-element_type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"aux-parallax-section elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-d79a474\" data-id=\"d79a474\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-e7ac2f1 elementor-widget elementor-widget-image\" data-id=\"e7ac2f1\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.12.1 - 02-04-2023 *\/\n.elementor-widget-image{text-align:center}.elementor-widget-image a{display:inline-block}.elementor-widget-image a img[src$=\".svg\"]{width:48px}.elementor-widget-image img{vertical-align:middle;display:inline-block}<\/style>\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"2560\" height=\"487\" src=\"https:\/\/caspianclients.com\/survey\/wp-content\/uploads\/2023\/03\/2023_0127_Landing_Page-012-scaled.jpg\" class=\"attachment-full size-full wp-image-120\" alt=\"\" srcset=\"https:\/\/caspianclients.com\/survey\/wp-content\/uploads\/2023\/03\/2023_0127_Landing_Page-012-scaled.jpg 2560w, https:\/\/caspianclients.com\/survey\/wp-content\/uploads\/2023\/03\/2023_0127_Landing_Page-012-1536x292.jpg 1536w, https:\/\/caspianclients.com\/survey\/wp-content\/uploads\/2023\/03\/2023_0127_Landing_Page-012-2048x390.jpg 2048w\" sizes=\"auto, (max-width: 2560px) 100vw, 2560px\" \/>\t\t\t\t\t\t\t\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-ae1b569 elementor-widget elementor-widget-heading\" data-id=\"ae1b569\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.12.1 - 02-04-2023 *\/\n.elementor-heading-title{padding:0;margin:0;line-height:1}.elementor-widget-heading .elementor-heading-title[class*=elementor-size-]>a{color:inherit;font-size:inherit;line-height:inherit}.elementor-widget-heading .elementor-heading-title.elementor-size-small{font-size:15px}.elementor-widget-heading .elementor-heading-title.elementor-size-medium{font-size:19px}.elementor-widget-heading .elementor-heading-title.elementor-size-large{font-size:29px}.elementor-widget-heading .elementor-heading-title.elementor-size-xl{font-size:39px}.elementor-widget-heading .elementor-heading-title.elementor-size-xxl{font-size:59px}<\/style><h4 class=\"elementor-heading-title elementor-size-default\">SEE IF YOU MAY PREQUALIFY<\/h4>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-bb51375 form-sections elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"bb51375\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"aux-parallax-section elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-8266336\" data-id=\"8266336\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-b10c64c elementor-widget elementor-widget-text-editor\" data-id=\"b10c64c\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.12.1 - 02-04-2023 *\/\n.elementor-widget-text-editor.elementor-drop-cap-view-stacked .elementor-drop-cap{background-color:#69727d;color:#fff}.elementor-widget-text-editor.elementor-drop-cap-view-framed .elementor-drop-cap{color:#69727d;border:3px solid;background-color:transparent}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap{margin-top:8px}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap-letter{width:1em;height:1em}.elementor-widget-text-editor .elementor-drop-cap{float:left;text-align:center;line-height:1;font-size:50px}.elementor-widget-text-editor .elementor-drop-cap-letter{display:inline-block}<\/style>\t\t\t\t<p>Volunteering for a clinical research study may be the first step to learning about your brain health and addressing symptoms of early Alzheimer\u2019s disease.<\/p>\n<p>Find out in minutes if you might pre-qualify to participate in a research study for an investigational drug to treat Alzheimer\u2019s disease by answering the questions below*.<\/p><p>None of the questions are mandatory and you do not have to answer any question(s) that you do not want to answer. Your answers will only be used to help decide if you may be eligible to participate in Alzheimer\u2019s research.<br><\/p>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-f68f830 elementor-widget elementor-widget-shortcode\" data-id=\"f68f830\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-shortcode\"><script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_1' >\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/survey\/wp-json\/wp\/v2\/pages\/109' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_1\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_1'>Participant Name<\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_1_1' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_118\" class=\"gfield gfield--type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_118'>Year of Birth<\/label><div class='ginput_container ginput_container_select'><select name='input_118' id='input_1_118' class='large gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='1920' >1920<\/option><option value='1921' >1921<\/option><option value='1922' >1922<\/option><option value='1923' >1923<\/option><option value='1924' >1924<\/option><option value='1925' >1925<\/option><option value='1926' >1926<\/option><option value='1927' >1927<\/option><option value='1928' >1928<\/option><option value='1929' >1929<\/option><option value='1930' >1930<\/option><option value='1931' >1931<\/option><option value='1932' >1932<\/option><option value='1933' >1933<\/option><option value='1934' >1934<\/option><option value='1935' >1935<\/option><option value='1936' >1936<\/option><option value='1937' >1937<\/option><option value='1938' >1938<\/option><option value='1939' >1939<\/option><option value='1940' >1940<\/option><option value='1941' >1941<\/option><option value='1942' >1942<\/option><option value='1943' >1943<\/option><option value='1944' >1944<\/option><option value='1945' >1945<\/option><option value='1946' >1946<\/option><option value='1947' >1947<\/option><option value='1948' >1948<\/option><option value='1949' >1949<\/option><option value='1950' >1950<\/option><option value='1951' >1951<\/option><option value='1952' >1952<\/option><option value='1953' >1953<\/option><option value='1954' >1954<\/option><option value='1955' >1955<\/option><option value='1956' >1956<\/option><option value='1957' >1957<\/option><option value='1958' >1958<\/option><option value='1959' >1959<\/option><option value='1960' >1960<\/option><option value='1961' >1961<\/option><option value='1962' >1962<\/option><option value='1963' >1963<\/option><option value='1964' >1964<\/option><option value='1965' >1965<\/option><option value='1966' >1966<\/option><option value='1967' >1967<\/option><option value='1968' >1968<\/option><option value='1969' >1969<\/option><option value='1970' >1970<\/option><option value='1971' >1971<\/option><option value='1972' >1972<\/option><option value='1973' >1973<\/option><option value='1974' >1974<\/option><option value='1975' >1975<\/option><option value='1976' >1976<\/option><option value='1977' >1977<\/option><option value='1978' >1978<\/option><option value='1979' >1979<\/option><option value='1980' >1980<\/option><option value='1981' >1981<\/option><option value='1982' >1982<\/option><option value='1983' >1983<\/option><option value='1984' >1984<\/option><option value='1985' >1985<\/option><option value='1986' >1986<\/option><option value='1987' >1987<\/option><option value='1988' >1988<\/option><option value='1989' >1989<\/option><option value='1990' >1990<\/option><option value='1991' >1991<\/option><option value='1992' >1992<\/option><option value='1993' >1993<\/option><option value='1994' >1994<\/option><option value='1995' >1995<\/option><option value='1996' >1996<\/option><option value='1997' >1997<\/option><option value='1998' >1998<\/option><option value='1999' >1999<\/option><\/select><\/div><\/div><div id=\"field_1_4\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_4'>Race\/Ethnicity<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_1_4' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_5\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_5'>Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_1_5' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_6\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Authorized to Leave a Detailed Voice Mail?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_6'>\n\t\t\t<div class='gchoice gchoice_1_6_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Yes'  id='choice_1_6_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_6_0' id='label_1_6_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_6_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='No'  id='choice_1_6_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_6_1' id='label_1_6_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_7\" class=\"gfield gfield--type-email gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_7'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_7' id='input_1_7' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_1_8\" class=\"gfield gfield--type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_8' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_8_1_container' >\n                                        <input type='text' name='input_8.1' id='input_1_8_1' value=''    aria-required='false'    \/>\n                                        <label for='input_1_8_1' id='input_1_8_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_8_3_container' >\n                                    <input type='text' name='input_8.3' id='input_1_8_3' value=''    aria-required='false'    \/>\n                                    <label for='input_1_8_3' id='input_1_8_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_8_4_container' >\n                                        <select name='input_8.4' id='input_1_8_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_1_8_4' id='input_1_8_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_8_5_container' >\n                                    <input type='text' name='input_8.5' id='input_1_8_5' value=''    aria-required='false'    \/>\n                                    <label for='input_1_8_5' id='input_1_8_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_8.6' id='input_1_8_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_1_119\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is this the Participant\u2019s full-time residence?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_119'>\n\t\t\t<div class='gchoice gchoice_1_119_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_119' type='radio' value='Yes'  id='choice_1_119_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_119_0' id='label_1_119_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_119_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_119' type='radio' value='No'  id='choice_1_119_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_119_1' id='label_1_119_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_9\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >If completing this form on behalf of someone else, please indicate your\nname and your relationship to the participant (i.e. spouse, adult child, etc.)<\/div><fieldset id=\"field_1_10\" class=\"gfield gfield--type-name gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_10'>\n                            \n                            <span id='input_1_10_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_10.3' id='input_1_10_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_10_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_10_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_10.6' id='input_1_10_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_10_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_11\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_11'>Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_1_11' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_12\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >User Agreement<\/legend><div class='ginput_container ginput_container_consent'><input name='input_12.1' id='input_1_12_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_1_12\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_12_1' >I agree.<\/label><input type='hidden' name='input_12.2' value='I agree.' class='gform_hidden' \/><input type='hidden' name='input_12.3' value='13' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_1_12' tabindex='0'>By signing up, I agree to be contacted about clinical research studies by the company Banner Alzheimer\u2019s Institute, its affiliates, or partners. Typical methods of contact include phone calls, text messages, pre-recorded messages, emails, automated technology or postal mail.<br \/>\n<br \/>\nAs we contact you, your electronic record will be updated accordingly with current relevant health information. This consent is not required to participate in a clinical research study.<br \/>\n<br \/>\nThe \u201cParticipant\u201d is the person who enrolls in the clinical trial. The \u201cStudy Partner\u201d is a family member\/friend or other person who can help complete the form and possibly assist the Participant with clinical trial participation. <br \/>\n<br \/>\nThe \u201cStudy Partner\u201d can assist the \u201cParticipant\u201d by helping answer the following health history questions. Answering the medical history is not mandatory and your answers will only be used to help decide if you may be eligible to participate in Alzheimer\u2019s research.<\/div><\/fieldset><div id=\"field_1_13\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >If you have any questions about this form or how your answers will be used, please contact Ashlyn Edward, site contact for the study from Banner Alzheimer\u2019s Institute at (520) 694-7021.<\/div><div id=\"field_1_14\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Study Participant Medical History<\/h3><\/div><fieldset id=\"field_1_15\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do You Have a Diagnosis of:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_15'><div class='gchoice gchoice_1_15_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.1' type='checkbox'  value='Alzheimer\u2019s disease'  id='choice_1_15_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_15_1' id='label_1_15_1' class='gform-field-label gform-field-label--type-inline'>Alzheimer\u2019s disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_15_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.2' type='checkbox'  value='Mild Cognitive Impairment'  id='choice_1_15_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_15_2' id='label_1_15_2' class='gform-field-label gform-field-label--type-inline'>Mild Cognitive Impairment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_15_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.3' type='checkbox'  value='Dementia\/Other Dementia'  id='choice_1_15_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_15_3' id='label_1_15_3' class='gform-field-label gform-field-label--type-inline'>Dementia\/Other Dementia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_15_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.4' type='checkbox'  value='No diagnosis\/Unknown'  id='choice_1_15_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_15_4' id='label_1_15_4' class='gform-field-label gform-field-label--type-inline'>No diagnosis\/Unknown<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_16\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_16'>Date of Diagnosis (if known):<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_16' id='input_1_16' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_16_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_16_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_16' class='gform_hidden' value='https:\/\/caspianclients.com\/survey\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_1_17\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you had memory decline with gradual onset and slow progression over the last 6 months?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_17'>\n\t\t\t<div class='gchoice gchoice_1_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Yes'  id='choice_1_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_17_0' id='label_1_17_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='No'  id='choice_1_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_17_1' id='label_1_17_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_18\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_18'>Notes<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_1_18' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_19\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have someone who could be a research study partner and attend regular visits with you and spends\/could spend at least 10 hours\/week with you?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_19'>\n\t\t\t<div class='gchoice gchoice_1_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Yes'  id='choice_1_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_19_0' id='label_1_19_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='No'  id='choice_1_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_19_1' id='label_1_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_20\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_20'>Notes<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_1_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you able and willing to attend regular research study visits approximately every 4 weeks for approximately 2.5 years?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_21'>\n\t\t\t<div class='gchoice gchoice_1_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Yes'  id='choice_1_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_21_0' id='label_1_21_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='No'  id='choice_1_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_21_1' id='label_1_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_22\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_22'>Notes<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_1_22' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_23\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you currently have cancer or a history of cancer?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_23'>\n\t\t\t<div class='gchoice gchoice_1_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Yes'  id='choice_1_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_23_0' id='label_1_23_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_1_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_23_1' id='label_1_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_24\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_24'>Current Type<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_1_24' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_25\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_25'>Past<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_1_25' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_26\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_26'>Last Treatment Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_26' id='input_1_26' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_26_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_26_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_26' class='gform_hidden' value='https:\/\/caspianclients.com\/survey\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_1_27\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have a history of depression, bipolar disorder, schizophrenia, anxiety or other mental health illness?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_27'>\n\t\t\t<div class='gchoice gchoice_1_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Yes'  id='choice_1_27_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_27_0' id='label_1_27_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='No'  id='choice_1_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_27_1' id='label_1_27_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_28\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_28'>Notes<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_1_28' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_29\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have a heart or respiratory condition? (Examples include unstable HTN, chronic health failure, COPD, emphysema, etc.)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_29'>\n\t\t\t<div class='gchoice gchoice_1_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Yes'  id='choice_1_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_29_0' id='label_1_29_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='No'  id='choice_1_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_29_1' id='label_1_29_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_30\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_30'>Notes<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_1_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_31\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have a history of stroke, neurological problems, or head trauma with loss of consciousness?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_31'>\n\t\t\t<div class='gchoice gchoice_1_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Yes'  id='choice_1_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_31_0' id='label_1_31_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='No'  id='choice_1_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_31_1' id='label_1_31_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_32\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_32'>Notes<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_1_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_33\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have any mental health illness and\/or medical condition not currently controlled by medication?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_33'>\n\t\t\t<div class='gchoice gchoice_1_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Yes'  id='choice_1_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_33_0' id='label_1_33_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='No'  id='choice_1_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_33_1' id='label_1_33_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_34\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_34'>Notes<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_1_34' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_35\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you get claustrophobia, have metal in your body (e.g., a pacemaker, metal implant, plates, etc) or have any other reason why you may not be able to endure an MRI or PET scan?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_35'>\n\t\t\t<div class='gchoice gchoice_1_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Yes'  id='choice_1_35_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_35_0' id='label_1_35_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='No'  id='choice_1_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_35_1' id='label_1_35_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_36\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_36'>Notes<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_1_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_37\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><span style=\"font-size: 21px;\"><b>Please rate your CURRENT level of difficulty performing the following everyday tasks by checking the most accurate answer:<\/b><\/span><\/div><fieldset id=\"field_1_38\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Remembering a few shopping items<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_38'>\n\t\t\t<div class='gchoice gchoice_1_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='No Difficulty'  id='choice_1_38_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_38_0' id='label_1_38_0' class='gform-field-label gform-field-label--type-inline'>No Difficulty<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Mild'  id='choice_1_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_38_1' id='label_1_38_1' class='gform-field-label gform-field-label--type-inline'>Mild<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_38_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Moderate'  id='choice_1_38_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_38_2' id='label_1_38_2' class='gform-field-label gform-field-label--type-inline'>Moderate<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_38_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Severe'  id='choice_1_38_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_38_3' id='label_1_38_3' class='gform-field-label gform-field-label--type-inline'>Severe<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_38_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Unable To Do'  id='choice_1_38_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_38_4' id='label_1_38_4' class='gform-field-label gform-field-label--type-inline'>Unable To Do<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_38_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='I Don\u2019t Know'  id='choice_1_38_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_38_5' id='label_1_38_5' class='gform-field-label gform-field-label--type-inline'>I Don\u2019t Know<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_39\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_39'>Notes<\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_1_39' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_40\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Remembering things that happened recently, such as outings within the past few weeks, events in the recent news, etc.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_40'>\n\t\t\t<div class='gchoice gchoice_1_40_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='No Difficulty'  id='choice_1_40_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_40_0' id='label_1_40_0' class='gform-field-label gform-field-label--type-inline'>No Difficulty<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_40_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Mild'  id='choice_1_40_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_40_1' id='label_1_40_1' class='gform-field-label gform-field-label--type-inline'>Mild<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_40_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Moderate'  id='choice_1_40_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_40_2' id='label_1_40_2' class='gform-field-label gform-field-label--type-inline'>Moderate<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_40_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Severe'  id='choice_1_40_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_40_3' id='label_1_40_3' class='gform-field-label gform-field-label--type-inline'>Severe<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_40_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Unable To Do'  id='choice_1_40_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_40_4' id='label_1_40_4' class='gform-field-label gform-field-label--type-inline'>Unable To Do<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_40_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='I Don\u2019t Know'  id='choice_1_40_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_40_5' id='label_1_40_5' class='gform-field-label gform-field-label--type-inline'>I Don\u2019t Know<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_41\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_41'>Notes<\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_1_41' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_42\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Recalling conversations a few days after they happened.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_42'>\n\t\t\t<div class='gchoice gchoice_1_42_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='No Difficulty'  id='choice_1_42_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_42_0' id='label_1_42_0' class='gform-field-label gform-field-label--type-inline'>No Difficulty<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_42_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Mild'  id='choice_1_42_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_42_1' id='label_1_42_1' class='gform-field-label gform-field-label--type-inline'>Mild<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_42_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Moderate'  id='choice_1_42_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_42_2' id='label_1_42_2' class='gform-field-label gform-field-label--type-inline'>Moderate<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_42_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Severe'  id='choice_1_42_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_42_3' id='label_1_42_3' class='gform-field-label gform-field-label--type-inline'>Severe<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_42_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Unable To Do'  id='choice_1_42_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_42_4' id='label_1_42_4' class='gform-field-label gform-field-label--type-inline'>Unable To Do<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_42_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='I Don\u2019t Know'  id='choice_1_42_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_42_5' id='label_1_42_5' class='gform-field-label gform-field-label--type-inline'>I Don\u2019t Know<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_43\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_43'>Notes<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_1_43' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_44\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Remembering where you placed objects.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_44'>\n\t\t\t<div class='gchoice gchoice_1_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='No Difficulty'  id='choice_1_44_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_44_0' id='label_1_44_0' class='gform-field-label gform-field-label--type-inline'>No Difficulty<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Mild'  id='choice_1_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_44_1' id='label_1_44_1' class='gform-field-label gform-field-label--type-inline'>Mild<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_44_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Moderate'  id='choice_1_44_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_44_2' id='label_1_44_2' class='gform-field-label gform-field-label--type-inline'>Moderate<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_44_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Severe'  id='choice_1_44_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_44_3' id='label_1_44_3' class='gform-field-label gform-field-label--type-inline'>Severe<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_44_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Unable To Do'  id='choice_1_44_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_44_4' id='label_1_44_4' class='gform-field-label gform-field-label--type-inline'>Unable To Do<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_44_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='I Don\u2019t Know'  id='choice_1_44_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_44_5' id='label_1_44_5' class='gform-field-label gform-field-label--type-inline'>I Don\u2019t Know<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_45\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_45'>Notes<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_1_45' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_46\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Participant\u2019s Medication List<\/h3><\/div><div id=\"field_1_103\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_103'>Medication<\/label><div class='ginput_container ginput_container_text'><input name='input_103' id='input_1_103' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_104\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_104'>Indication<\/label><div class='ginput_container ginput_container_text'><input name='input_104' id='input_1_104' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_105\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_105'>Dose<\/label><div class='ginput_container ginput_container_text'><input name='input_105' id='input_1_105' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_106\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_106'>Start Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_106' id='input_1_106' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_106_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_106_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_106' class='gform_hidden' value='https:\/\/caspianclients.com\/survey\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_107\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_107'>End Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_107' id='input_1_107' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_107_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_107_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_107' class='gform_hidden' value='https:\/\/caspianclients.com\/survey\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_109\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><hr><\/p><\/div><div id=\"field_1_98\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_98'>Medication<\/label><div class='ginput_container ginput_container_text'><input name='input_98' id='input_1_98' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_99\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_99'>Indication<\/label><div class='ginput_container ginput_container_text'><input name='input_99' id='input_1_99' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_100\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_100'>Dose<\/label><div class='ginput_container ginput_container_text'><input name='input_100' id='input_1_100' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_101\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_101'>Start Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_101' id='input_1_101' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_101_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_101_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_101' class='gform_hidden' value='https:\/\/caspianclients.com\/survey\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_102\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_102'>End Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_102' id='input_1_102' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_102_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_102_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_102' class='gform_hidden' value='https:\/\/caspianclients.com\/survey\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_110\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><hr><\/p><\/div><div id=\"field_1_93\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_93'>Medication<\/label><div class='ginput_container ginput_container_text'><input name='input_93' id='input_1_93' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_94\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_94'>Indication<\/label><div class='ginput_container ginput_container_text'><input name='input_94' id='input_1_94' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_95\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_95'>Dose<\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_1_95' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_96\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_96'>Start Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_96' id='input_1_96' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_96_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_96_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_96' class='gform_hidden' value='https:\/\/caspianclients.com\/survey\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_97\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_97'>End Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_97' id='input_1_97' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_97_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_97_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_97' class='gform_hidden' value='https:\/\/caspianclients.com\/survey\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_111\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><hr><\/p><\/div><div id=\"field_1_88\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_88'>Medication<\/label><div class='ginput_container ginput_container_text'><input name='input_88' id='input_1_88' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_89\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_89'>Indication<\/label><div class='ginput_container ginput_container_text'><input name='input_89' id='input_1_89' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_90\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_90'>Dose<\/label><div class='ginput_container ginput_container_text'><input name='input_90' id='input_1_90' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_91\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_91'>Start Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_91' id='input_1_91' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_91_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_91_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_91' class='gform_hidden' value='https:\/\/caspianclients.com\/survey\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_92\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_92'>End Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_92' id='input_1_92' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_92_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_92_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_92' class='gform_hidden' value='https:\/\/caspianclients.com\/survey\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_112\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><hr><\/p><\/div><div id=\"field_1_83\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_83'>Medication<\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_1_83' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_84\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_84'>Indication<\/label><div class='ginput_container ginput_container_text'><input name='input_84' id='input_1_84' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_85\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_85'>Dose<\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_1_85' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_86\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_86'>Start Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_86' id='input_1_86' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_86_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_86_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_86' class='gform_hidden' value='https:\/\/caspianclients.com\/survey\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_87\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_87'>End Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_87' id='input_1_87' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_87_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_87_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_87' class='gform_hidden' value='https:\/\/caspianclients.com\/survey\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_113\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><hr><\/p><\/div><div id=\"field_1_78\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_78'>Medication<\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_1_78' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_79\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_79'>Indication<\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_1_79' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_80\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_80'>Dose<\/label><div class='ginput_container ginput_container_text'><input name='input_80' id='input_1_80' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_81\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_81'>Start Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_81' id='input_1_81' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_81_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_81_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_81' class='gform_hidden' value='https:\/\/caspianclients.com\/survey\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_82\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_82'>End Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_82' id='input_1_82' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_82_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_82_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_82' class='gform_hidden' value='https:\/\/caspianclients.com\/survey\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_114\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><hr><\/p><\/div><div id=\"field_1_47\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_47'>Medication<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_1_47' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_48\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_48'>Indication<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_1_48' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_49\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_49'>Dose<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_1_49' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_50\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_50'>Start Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_50' id='input_1_50' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_50_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_50_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_50' class='gform_hidden' value='https:\/\/caspianclients.com\/survey\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_51\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_51'>End Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_51' id='input_1_51' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_51_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_51_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_51' class='gform_hidden' value='https:\/\/caspianclients.com\/survey\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_115\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><hr><\/p><\/div><div id=\"field_1_52\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_52'>Medication<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_1_52' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_53\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_53'>Indication<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_1_53' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_54\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_54'>Dose<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_1_54' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_55\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_55'>Start Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_55' id='input_1_55' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_55_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_55_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_55' class='gform_hidden' value='https:\/\/caspianclients.com\/survey\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_56\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_56'>End Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_56' id='input_1_56' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_56_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_56_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_56' class='gform_hidden' value='https:\/\/caspianclients.com\/survey\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_116\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><hr><\/p><\/div><div id=\"field_1_61\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_61'>Medication<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_1_61' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_60\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_60'>Indication<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_1_60' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_57\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_57'>Dose<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_1_57' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_58\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_58'>Start Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_58' id='input_1_58' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_58_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_58_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_58' class='gform_hidden' value='https:\/\/caspianclients.com\/survey\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_59\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_59'>End Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_59' id='input_1_59' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_59_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_59_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_59' class='gform_hidden' value='https:\/\/caspianclients.com\/survey\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_117\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><hr><\/p><\/div><div id=\"field_1_76\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_76'>Medication<\/label><div class='ginput_container ginput_container_text'><input name='input_76' id='input_1_76' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_77\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_77'>Indication<\/label><div class='ginput_container ginput_container_text'><input name='input_77' id='input_1_77' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_75\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_75'>Dose<\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_1_75' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_74\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_74'>Start Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_74' id='input_1_74' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_74_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_74_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_74' class='gform_hidden' value='https:\/\/caspianclients.com\/survey\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_73\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_73'>End Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_73' id='input_1_73' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_73_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_73_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_73' class='gform_hidden' value='https:\/\/caspianclients.com\/survey\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_62\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Study Partner Information (if available)<\/h3><\/div><fieldset id=\"field_1_63\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you\/can you spend at least 10 hours a week with the study Participant?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_63'>\n\t\t\t<div class='gchoice gchoice_1_63_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Yes'  id='choice_1_63_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_63_0' id='label_1_63_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_63_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='No'  id='choice_1_63_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_63_1' id='label_1_63_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_64\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_64'>Notes<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_1_64' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_120\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_120'>How long have you known the Participant?<\/label><div class='ginput_container ginput_container_text'><input name='input_120' id='input_1_120' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_120\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_120'>Years<\/div><\/div><div id=\"field_1_121\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_121'>How many hours per week do you currently spend with the study Participant?<\/label><div class='ginput_container ginput_container_text'><input name='input_121' id='input_1_121' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_121\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_121'>Hours<\/div><\/div><div id=\"field_1_67\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">If this form is completed by the study participant, please check boxes below to submit:<\/h3><\/div><fieldset id=\"field_1_68\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<\/legend><div class='ginput_container ginput_container_consent'><input name='input_68.1' id='input_1_68_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_1_68\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_68_1' >I agree<\/label><input type='hidden' name='input_68.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_68.3' value='13' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_1_68' tabindex='0'>By checking this box, I am willfully sharing this information with the research site and consent to their receipt. I authorize Banner Alzheimer\u2019s Institute to contact me if I am eligible or not eligible to participate in a research study about Alzheimer\u2019s disease.<\/div><\/fieldset><fieldset id=\"field_1_69\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<\/legend><div class='ginput_container ginput_container_consent'><input name='input_69.1' id='input_1_69_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_1_69\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_69_1' >I agree<\/label><input type='hidden' name='input_69.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_69.3' value='13' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_1_69' tabindex='0'>By checking this box, I consent to contact from the research site. If I am not currently eligible for a research study, Banner Alzheimer\u2019s Institute is authorized to contact me or my designee in the future for other related opportunities. This may include educational events, registries, or other activities that may be of interest to me.<\/div><\/fieldset><div id=\"field_1_70\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">If this form is completed by the study partner, please check boxes below to submit:<\/h3><\/div><fieldset id=\"field_1_71\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<\/legend><div class='ginput_container ginput_container_consent'><input name='input_71.1' id='input_1_71_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_1_71\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_71_1' >I agree<\/label><input type='hidden' name='input_71.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_71.3' value='13' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_1_71' tabindex='0'>By checking this box, I authorize Banner Alzheimer\u2019s Institute to contact me if the Participant is eligible or not eligible to participate in a research study about Alzheimer\u2019s disease.<\/div><\/fieldset><fieldset id=\"field_1_72\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<\/legend><div class='ginput_container ginput_container_consent'><input name='input_72.1' id='input_1_72_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_1_72\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_72_1' >I agree<\/label><input type='hidden' name='input_72.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_72.3' value='13' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_1_72' tabindex='0'>If the participant is not currently eligible for a research study, Banner Alzheimer\u2019s Institute is authorized to contact me in the future for other related opportunities. 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