{"id":3130,"date":"2023-03-29T17:17:10","date_gmt":"2023-03-29T17:17:10","guid":{"rendered":"https:\/\/tossadivers.com\/documentation\/"},"modified":"2024-02-11T10:20:36","modified_gmt":"2024-02-11T10:20:36","slug":"documentation","status":"publish","type":"page","link":"https:\/\/tossadivers.com\/fr\/documentation\/","title":{"rendered":"Documentation"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3130\" class=\"elementor elementor-3130 elementor-2004\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-c3eee29 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"c3eee29\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-f831768\" data-id=\"f831768\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-5f274cc elementor-widget elementor-widget-heading\" data-id=\"5f274cc\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Check-In TossaDivers<\/h2>\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\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-75efea4 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"75efea4\" 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=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-adfcd71\" data-id=\"adfcd71\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-d1f6d98 elementor-widget elementor-widget-shortcode\" data-id=\"d1f6d98\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script type=\"text\/javascript\">var 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 InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return 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)}});<\/script>\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_7' style='display:none'><div id='gf_7' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>\u00ab\u00a0<span class=\"gfield_required gfield_required_asterisk\">*<\/span>\u00a0\u00bb indique les champs n\u00e9cessaires<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_7' id='gform_7'  action='\/fr\/wp-json\/wp\/v2\/pages\/3130#gf_7' data-formid='7' novalidate>\n        <div id='gf_progressbar_wrapper_7' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">\u00c9tape <span class='gf_step_current_page'>1<\/span> sur <span class='gf_step_page_count'>5<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_20' style='width:20%;'><span>20%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_7_1' class='gform_page ' data-js='page-field-id-0' >\n                                    <div class='gform_page_fields'><div id='gform_fields_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_7_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_1\" ><label class='gfield_label gform-field-label' for='input_7_1'>Nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_7_1' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_2\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_2\" ><label class='gfield_label gform-field-label' for='input_7_2'>Noms de famille<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_7_2' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_5\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_5\" ><label class='gfield_label gform-field-label' for='input_7_5'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_7_5' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_7_6\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_6\" ><label class='gfield_label gform-field-label' for='input_7_6'>T\u00e9l\u00e9phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_7_6' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_7_68\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_68\" ><legend class='gfield_label gform-field-label' >Tu es majeur ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_68'>\n\t\t\t<div class='gchoice gchoice_7_68_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Oui'  id='choice_7_68_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_68_0' id='label_7_68_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_68_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='No'  id='choice_7_68_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_68_1' id='label_7_68_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_8\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_8\" ><label class='gfield_label gform-field-label' for='input_7_8'>Date de r\u00e9ponse au formulaire<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_8' id='input_7_8' type='text' value='--' class='datepicker gform-datepicker dmy_dash datepicker_with_icon gdatepicker_with_icon'   placeholder='19\/04\/2025' aria-describedby=\"input_7_8_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_7_8_date_format' class='screen-reader-text'>JJ - MM - AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_8' class='gform_hidden' value='https:\/\/tossadivers.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_7_69\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_69\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Donn\u00e9es du tuteur l\u00e9gal<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_7_69'>\n                            \n                            <span id='input_7_69_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_69.3' id='input_7_69_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_7_69_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_7_69_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_69.6' id='input_7_69_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_7_69_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_7_70\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_70\" ><label class='gfield_label gform-field-label' for='input_7_70'>Signature du tuteur l\u00e9gal<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_7_70_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_7_70_valid' id='input_7_70_valid' \/><canvas id='input_7_70' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/tossadivers.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_7_70_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img decoding=\"async\" id=\"input_7_70_resetbutton\" src=\"data:image\/png;base64,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\" style=\"cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent\" alt=\"Clear Signature\" title=\"\"><\/div><input type='hidden' id='input_7_70_data' name='input_7_70_data' value=''><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_7_76' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' value='Suivant '  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_2' class='gform_page' data-js='page-field-id-76' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_7_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_7_79\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_79\" ><h3 class=\"gsection_title\">questionnaire m\u00e9dical<\/h3><\/div><fieldset id=\"field_7_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_9\" ><legend class='gfield_label gform-field-label' >1 - J&#039;ai eu des probl\u00e8mes pulmonaires, respiratoires, cardiaques et\/ou sanguins qui affectent mes performances physiques ou mentales normales (Si vous r\u00e9pondez OUI, r\u00e9pondez aux questions A)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_9'>\n\t\t\t<div class='gchoice gchoice_7_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Oui'  id='choice_7_9_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_9_0' id='label_7_9_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='No'  id='choice_7_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_9_1' id='label_7_9_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_10\" ><legend class='gfield_label gform-field-label' >2 - J&#039;ai plus de 45 ans (Si vous r\u00e9pondez OUI, r\u00e9pondez aux questions B)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_10'>\n\t\t\t<div class='gchoice gchoice_7_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Oui'  id='choice_7_10_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_10_0' id='label_7_10_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_10_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='No'  id='choice_7_10_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_10_1' id='label_7_10_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_11\" ><legend class='gfield_label gform-field-label' >3 - J&#039;ai des difficult\u00e9s \u00e0 faire des exercices mod\u00e9r\u00e9s (par exemple, marcher 1,6 kilom\u00e8tre en 12 minutes ou nager 200 m\u00e8tres sans repos), ou je n&#039;ai pas pu participer \u00e0 une activit\u00e9 physique normale pour des raisons physiques ou de sant\u00e9 au cours des 12 derniers mois.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_11'>\n\t\t\t<div class='gchoice gchoice_7_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Oui'  id='choice_7_11_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_11_0' id='label_7_11_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='No'  id='choice_7_11_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_11_1' id='label_7_11_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_12\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_12\" ><legend class='gfield_label gform-field-label' >4 - J&#039;ai eu des probl\u00e8mes aux yeux, aux oreilles, aux voies nasales ou aux sinus. (Si vous r\u00e9pondez OUI, r\u00e9pondez aux questions C)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_12'>\n\t\t\t<div class='gchoice gchoice_7_12_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Oui'  id='choice_7_12_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_12_0' id='label_7_12_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_12_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='No'  id='choice_7_12_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_12_1' id='label_7_12_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_13\" ><legend class='gfield_label gform-field-label' >5 - J&#039;ai subi une intervention chirurgicale au cours des 12 derniers mois ou j&#039;ai des probl\u00e8mes persistants li\u00e9s \u00e0 une intervention chirurgicale ant\u00e9rieure<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_13'>\n\t\t\t<div class='gchoice gchoice_7_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Oui'  id='choice_7_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_13_0' id='label_7_13_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='No'  id='choice_7_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_13_1' id='label_7_13_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_14\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_14\" ><legend class='gfield_label gform-field-label' >6 - J&#039;ai perdu connaissance, j&#039;ai eu des migraines, des convulsions, un accident vasculaire c\u00e9r\u00e9bral, un traumatisme cr\u00e2nien important ou j&#039;ai souffert d&#039;une l\u00e9sion ou d&#039;une maladie neurologique persistante. (Si vous r\u00e9pondez OUI, r\u00e9pondez aux questions D)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_14'>\n\t\t\t<div class='gchoice gchoice_7_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Oui'  id='choice_7_14_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_14_0' id='label_7_14_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='No'  id='choice_7_14_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_14_1' id='label_7_14_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_15\" ><legend class='gfield_label gform-field-label' >7 - J&#039;ai eu des probl\u00e8mes psychologiques, on m&#039;a diagnostiqu\u00e9 un trouble d&#039;apprentissage, un trouble de la personnalit\u00e9, des crises de panique ou une d\u00e9pendance \u00e0 la drogue ou \u00e0 l&#039;alcool (Si vous r\u00e9pondez OUI, r\u00e9pondez aux questions E)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_15'>\n\t\t\t<div class='gchoice gchoice_7_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Oui'  id='choice_7_15_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_15_0' id='label_7_15_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='No'  id='choice_7_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_15_1' id='label_7_15_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_16\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_16\" ><legend class='gfield_label gform-field-label' >8 - J&#039;ai eu des probl\u00e8mes de dos, de hernie, d&#039;ulc\u00e8res ou de diab\u00e8te. (Si vous r\u00e9pondez OUI, r\u00e9pondez aux questions F)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_16'>\n\t\t\t<div class='gchoice gchoice_7_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Oui'  id='choice_7_16_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_16_0' id='label_7_16_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='No'  id='choice_7_16_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_16_1' id='label_7_16_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_17\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_17\" ><legend class='gfield_label gform-field-label' >9 - J&#039;ai eu des probl\u00e8mes d&#039;estomac ou d&#039;intestins, y compris une diarrh\u00e9e r\u00e9cente. (Si vous r\u00e9pondez OUI, r\u00e9pondez \u00e0 la question G)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_17'>\n\t\t\t<div class='gchoice gchoice_7_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Oui'  id='choice_7_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_17_0' id='label_7_17_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='No'  id='choice_7_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_17_1' id='label_7_17_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_18\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_18\" ><legend class='gfield_label gform-field-label' >10 - Je prends des m\u00e9dicaments sur ordonnance (\u00e0 l&#039;exception des contraceptifs ou des m\u00e9dicaments antipaludiques).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_18'>\n\t\t\t<div class='gchoice gchoice_7_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Oui'  id='choice_7_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_18_0' id='label_7_18_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='No'  id='choice_7_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_18_1' id='label_7_18_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_54\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_54\" ><h3 class=\"gsection_title\">Section A<\/h3><\/div><fieldset id=\"field_7_19\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_19\" ><legend class='gfield_label gform-field-label' >A1 - J&#039;ai\/ai eu : une chirurgie thoracique, une chirurgie cardiaque, une chirurgie valvulaire cardiaque, la pose d&#039;un stent ou un pneumothorax (poumon affaiss\u00e9).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_19'>\n\t\t\t<div class='gchoice gchoice_7_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Oui'  id='choice_7_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_19_0' id='label_7_19_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='No'  id='choice_7_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_19_1' id='label_7_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_20\" ><legend class='gfield_label gform-field-label' >A2 \u2014 J&#039;ai\/ai eu : de l&#039;asthme, une respiration sifflante, des allergies graves, le rhume des foins ou des voies respiratoires congestionn\u00e9es au cours des 12 derniers mois qui limitent mon activit\u00e9 physique ou mon exercice.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_20'>\n\t\t\t<div class='gchoice gchoice_7_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Oui'  id='choice_7_20_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_20_0' id='label_7_20_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='No'  id='choice_7_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_20_1' id='label_7_20_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_21\" ><legend class='gfield_label gform-field-label' >A3 \u2014 J&#039;ai\/ai eu : Un probl\u00e8me ou une maladie impliquant mon c\u0153ur tel que : angine de poitrine, douleur thoracique \u00e0 l&#039;effort, insuffisance cardiaque, \u0153d\u00e8me pulmonaire, cardiomyopathie ou accident vasculaire c\u00e9r\u00e9bral, ou je prends des m\u00e9dicaments pour une maladie cardiaque.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_21'>\n\t\t\t<div class='gchoice gchoice_7_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Oui'  id='choice_7_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_21_0' id='label_7_21_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='No'  id='choice_7_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_21_1' id='label_7_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_22\" ><legend class='gfield_label gform-field-label' >A4 \u2014 J&#039;ai\/ai eu : Une bronchite r\u00e9currente et une toux persistante au cours des 12 derniers mois, ou j&#039;ai re\u00e7u un diagnostic d&#039;emphys\u00e8me.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_22'>\n\t\t\t<div class='gchoice gchoice_7_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Oui'  id='choice_7_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_22_0' id='label_7_22_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='No'  id='choice_7_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_22_1' id='label_7_22_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_23\" ><legend class='gfield_label gform-field-label' >A5\u2014 Sympt\u00f4mes affectant mes poumons, ma respiration, mon c\u0153ur et\/ou mon sang au cours des 30 derniers jours et nuisant \u00e0 mes performances physiques ou mentales.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_23'>\n\t\t\t<div class='gchoice gchoice_7_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Oui'  id='choice_7_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_23_0' id='label_7_23_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_7_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_23_1' id='label_7_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_55\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_55\" ><h3 class=\"gsection_title\">Section B<\/h3><\/div><fieldset id=\"field_7_24\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_24\" ><legend class='gfield_label gform-field-label' >B1 \u2014 J&#039;ai plus de 45 ans et je fume ou inhale actuellement de la nicotine par d&#039;autres moyens.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_24'>\n\t\t\t<div class='gchoice gchoice_7_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Oui'  id='choice_7_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_24_0' id='label_7_24_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='No'  id='choice_7_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_24_1' id='label_7_24_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_25\" ><legend class='gfield_label gform-field-label' >B2 \u2014 J&#039;ai plus de 45 ans et mon taux de cholest\u00e9rol est nul.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_25'>\n\t\t\t<div class='gchoice gchoice_7_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Oui'  id='choice_7_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_25_0' id='label_7_25_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='No'  id='choice_7_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_25_1' id='label_7_25_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_26\" ><legend class='gfield_label gform-field-label' >B3 \u2014 J&#039;ai plus de 45 ans et je souffre d&#039;hypertension.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_26'>\n\t\t\t<div class='gchoice gchoice_7_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Oui'  id='choice_7_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_26_0' id='label_7_26_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='No'  id='choice_7_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_26_1' id='label_7_26_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_27\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_27\" ><legend class='gfield_label gform-field-label' >B4 - J&#039;ai plus de 45 ans et j&#039;ai eu un proche (1er ou 2\u00e8me degr\u00e9 de consanguinit\u00e9) d\u00e9c\u00e9d\u00e9 subitement 0 de maladie cardiaque 0 d&#039;accident vasculaire c\u00e9r\u00e9bral avant 50 ans, 0 J&#039;ai des ant\u00e9c\u00e9dents familiaux de maladie cardiaque avant 50 ans (y compris des rythmes cardiaques anormaux, une maladie coronarienne ou une cardiomyopathie)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_27'>\n\t\t\t<div class='gchoice gchoice_7_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Oui'  id='choice_7_27_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_27_0' id='label_7_27_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='No'  id='choice_7_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_27_1' id='label_7_27_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_56\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_56\" ><h3 class=\"gsection_title\">Section C<\/h3><\/div><fieldset id=\"field_7_28\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_28\" ><legend class='gfield_label gform-field-label' >C1 \u2014 J&#039;ai\/ai eu : Chirurgie des sinus au cours des 6 derniers mois.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_28'>\n\t\t\t<div class='gchoice gchoice_7_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Oui'  id='choice_7_28_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_28_0' id='label_7_28_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='No'  id='choice_7_28_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_28_1' id='label_7_28_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_29\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_29\" ><legend class='gfield_label gform-field-label' >C2 \u2014 J&#039;ai\/ai eu : Des maladies ou chirurgies de l&#039;oreille, une perte auditive ou des troubles de l&#039;\u00e9quilibre.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_29'>\n\t\t\t<div class='gchoice gchoice_7_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Oui'  id='choice_7_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_29_0' id='label_7_29_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='No'  id='choice_7_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_29_1' id='label_7_29_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_30\" ><legend class='gfield_label gform-field-label' >C3 \u2014 J&#039;ai\/ai eu : Une sinusite r\u00e9currente au cours des 12 derniers mois.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_30'>\n\t\t\t<div class='gchoice gchoice_7_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Oui'  id='choice_7_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_30_0' id='label_7_30_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='No'  id='choice_7_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_30_1' id='label_7_30_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_31\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_31\" ><legend class='gfield_label gform-field-label' >C4 \u2014 J&#039;ai\/ai subi : une chirurgie oculaire au cours des 3 derniers mois.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_31'>\n\t\t\t<div class='gchoice gchoice_7_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Oui'  id='choice_7_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_31_0' id='label_7_31_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='No'  id='choice_7_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_31_1' id='label_7_31_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_57\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_57\" ><h3 class=\"gsection_title\">Section D<\/h3><\/div><fieldset id=\"field_7_32\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_32\" ><legend class='gfield_label gform-field-label' >D1 \u2014 J&#039;ai\/ai eu : Un traumatisme cr\u00e2nien avec perte de conscience au cours des 5 derni\u00e8res ann\u00e9es.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_32'>\n\t\t\t<div class='gchoice gchoice_7_32_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Oui'  id='choice_7_32_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_32_0' id='label_7_32_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_32_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='No'  id='choice_7_32_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_32_1' id='label_7_32_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_33\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_33\" ><legend class='gfield_label gform-field-label' >D2 \u2014 J&#039;ai\/ai eu : Des l\u00e9sions ou maladies neurologiques persistantes.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_33'>\n\t\t\t<div class='gchoice gchoice_7_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Oui'  id='choice_7_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_33_0' id='label_7_33_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='No'  id='choice_7_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_33_1' id='label_7_33_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_34\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_34\" ><legend class='gfield_label gform-field-label' >D3 \u2014 J&#039;ai\/ai eu : Des migraines r\u00e9currentes au cours des 12 derniers mois, ou je prends des m\u00e9dicaments pour les pr\u00e9venir.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_34'>\n\t\t\t<div class='gchoice gchoice_7_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Oui'  id='choice_7_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_34_0' id='label_7_34_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='No'  id='choice_7_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_34_1' id='label_7_34_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_35\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_35\" ><legend class='gfield_label gform-field-label' >D4 \u2014 J&#039;ai\/ai eu : Des \u00e9vanouissements ou des \u00e9vanouissements (perte de conscience totale\/partielle) au cours des 5 derni\u00e8res ann\u00e9es.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_35'>\n\t\t\t<div class='gchoice gchoice_7_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Oui'  id='choice_7_35_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_35_0' id='label_7_35_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='No'  id='choice_7_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_35_1' id='label_7_35_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_36\" ><legend class='gfield_label gform-field-label' >D5 \u2014 J&#039;ai\/ai eu : de l&#039;\u00e9pilepsie, des convulsions ou des convulsions, ou je prends des m\u00e9dicaments pour les pr\u00e9venir.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_36'>\n\t\t\t<div class='gchoice gchoice_7_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Oui'  id='choice_7_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_36_0' id='label_7_36_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='No'  id='choice_7_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_36_1' id='label_7_36_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_59\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_59\" ><h3 class=\"gsection_title\">Section E<\/h3><\/div><fieldset id=\"field_7_37\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_37\" ><legend class='gfield_label gform-field-label' >E1 \u2014 J&#039;ai\/ai eu : Des probl\u00e8mes de sant\u00e9 comportementale, mentaux ou psychologiques n\u00e9cessitant un traitement m\u00e9dical ou psychiatrique.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_37'>\n\t\t\t<div class='gchoice gchoice_7_37_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Oui'  id='choice_7_37_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_37_0' id='label_7_37_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_37_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='No'  id='choice_7_37_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_37_1' id='label_7_37_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_38\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_38\" ><legend class='gfield_label gform-field-label' >E2 \u2014 J&#039;ai\/ai eu : D\u00e9pression majeure, tendances suicidaires, crises de panique, trouble bipolaire incontr\u00f4l\u00e9 n\u00e9cessitant un traitement m\u00e9dicamenteux\/psychiatrique.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_38'>\n\t\t\t<div class='gchoice gchoice_7_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Oui'  id='choice_7_38_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_38_0' id='label_7_38_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='No'  id='choice_7_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_38_1' id='label_7_38_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_39\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_39\" ><legend class='gfield_label gform-field-label' >E3 \u2014 J&#039;ai\/ai eu : On m&#039;a diagnostiqu\u00e9 un probl\u00e8me de sant\u00e9 mentale ou un trouble d&#039;apprentissage ou de d\u00e9veloppement qui n\u00e9cessite des soins continus.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_39'>\n\t\t\t<div class='gchoice gchoice_7_39_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Oui'  id='choice_7_39_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_39_0' id='label_7_39_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_39_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='No'  id='choice_7_39_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_39_1' id='label_7_39_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_40\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_40\" ><legend class='gfield_label gform-field-label' >E4 \u2014 J&#039;ai\/ai eu : Une d\u00e9pendance \u00e0 une drogue ou \u00e0 l&#039;alcool qui n\u00e9cessite un traitement au cours des 5 derni\u00e8res ann\u00e9es.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_40'>\n\t\t\t<div class='gchoice gchoice_7_40_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Oui'  id='choice_7_40_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_40_0' id='label_7_40_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_40_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='No'  id='choice_7_40_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_40_1' id='label_7_40_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_58\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_58\" ><h3 class=\"gsection_title\">Section F<\/h3><\/div><fieldset id=\"field_7_41\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_41\" ><legend class='gfield_label gform-field-label' >F1 \u2014 J&#039;ai\/ai eu : Des probl\u00e8mes de dos r\u00e9currents au cours des 6 derniers mois qui limitent mon activit\u00e9 quotidienne.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_41'>\n\t\t\t<div class='gchoice gchoice_7_41_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Oui'  id='choice_7_41_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_41_0' id='label_7_41_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_41_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='No'  id='choice_7_41_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_41_1' id='label_7_41_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_42\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_42\" ><legend class='gfield_label gform-field-label' >F2 \u2014 J&#039;ai\/ai subi : une op\u00e9ration du dos ou de la colonne vert\u00e9brale au cours des 12 derniers mois.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_42'>\n\t\t\t<div class='gchoice gchoice_7_42_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Oui'  id='choice_7_42_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_42_0' id='label_7_42_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_42_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='No'  id='choice_7_42_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_42_1' id='label_7_42_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_45\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_45\" ><legend class='gfield_label gform-field-label' >F3 \u2014 J&#039;ai\/ai eu : Un diab\u00e8te, contr\u00f4l\u00e9 par l&#039;insuline ou un r\u00e9gime, ou un diab\u00e8te gestationnel au cours des 12 derniers mois.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_45'>\n\t\t\t<div class='gchoice gchoice_7_45_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='Oui'  id='choice_7_45_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_45_0' id='label_7_45_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_45_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='No'  id='choice_7_45_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_45_1' id='label_7_45_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_43\" ><legend class='gfield_label gform-field-label' >F4 \u2014 J&#039;ai\/ai eu : Une hernie non corrig\u00e9e qui limite mes capacit\u00e9s physiques.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_43'>\n\t\t\t<div class='gchoice gchoice_7_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Oui'  id='choice_7_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_43_0' id='label_7_43_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='No'  id='choice_7_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_43_1' id='label_7_43_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_44\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_44\" ><legend class='gfield_label gform-field-label' >F5 \u2014 J&#039;ai\/ai eu : Actif 0 ulc\u00e8re non trait\u00e9, plaie probl\u00e9matique 0 chirurgie ulc\u00e9reuse au cours des 6 derniers mois.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_44'>\n\t\t\t<div class='gchoice gchoice_7_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Oui'  id='choice_7_44_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_44_0' id='label_7_44_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='No'  id='choice_7_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_44_1' id='label_7_44_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_60\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_60\" ><h3 class=\"gsection_title\">Section G<\/h3><\/div><fieldset id=\"field_7_46\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_46\" ><legend class='gfield_label gform-field-label' >G1 \u2014 J&#039;ai subi : une op\u00e9ration de stomie et je ne suis pas m\u00e9dicalement autoris\u00e9 \u00e0 nager ou \u00e0 pratiquer une activit\u00e9 physique.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_46'>\n\t\t\t<div class='gchoice gchoice_7_46_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Oui'  id='choice_7_46_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_46_0' id='label_7_46_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_46_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='No'  id='choice_7_46_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_46_1' id='label_7_46_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_47\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_47\" ><legend class='gfield_label gform-field-label' >G2 \u2014 J&#039;ai : D\u00e9shydratation n\u00e9cessitant une intervention m\u00e9dicale au cours des 7 derniers jours.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_47'>\n\t\t\t<div class='gchoice gchoice_7_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Oui'  id='choice_7_47_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_47_0' id='label_7_47_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='No'  id='choice_7_47_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_47_1' id='label_7_47_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_48\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_48\" ><legend class='gfield_label gform-field-label' >G3 \u2014 J&#039;ai : Des ulc\u00e8res gastriques ou intestinaux actifs ou non trait\u00e9s ou une chirurgie ulc\u00e9reuse au cours des 6 derniers mois.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_48'>\n\t\t\t<div class='gchoice gchoice_7_48_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='Oui'  id='choice_7_48_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_48_0' id='label_7_48_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_48_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='No'  id='choice_7_48_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_48_1' id='label_7_48_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_49\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_49\" ><legend class='gfield_label gform-field-label' >G4 \u2014 J&#039;ai : des br\u00fblures d&#039;estomac fr\u00e9quentes, des r\u00e9gurgitations ou un reflux astro-\u0153sophagien (RGO)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_49'>\n\t\t\t<div class='gchoice gchoice_7_49_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Oui'  id='choice_7_49_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_49_0' id='label_7_49_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_49_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='No'  id='choice_7_49_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_49_1' id='label_7_49_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_50\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_50\" ><legend class='gfield_label gform-field-label' >G5 \u2014 J&#039;ai : une colite ulc\u00e9reuse active ou incontr\u00f4l\u00e9e ou la maladie de Crohn.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_50'>\n\t\t\t<div class='gchoice gchoice_7_50_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Oui'  id='choice_7_50_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_50_0' id='label_7_50_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_50_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='No'  id='choice_7_50_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_50_1' id='label_7_50_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_51\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_51\" ><legend class='gfield_label gform-field-label' >G6 \u2014 J&#039;ai : Chirurgie bariatrique au cours des 12 derniers mois.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_51'>\n\t\t\t<div class='gchoice gchoice_7_51_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='Oui'  id='choice_7_51_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_51_0' id='label_7_51_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_51_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='No'  id='choice_7_51_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_51_1' id='label_7_51_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_61\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_61\" ><h3 class=\"gsection_title\">Acceptation de la d\u00e9claration<\/h3><\/div><fieldset id=\"field_7_52\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_52\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Si vous avez r\u00e9pondu OUI aux questions 3, 5 ou 10 ci-dessus ou \u00e0 l&#039;une des questions du questionnaire, veuillez t\u00e9l\u00e9charger, lire et accepter la d\u00e9claration dat\u00e9e et sign\u00e9e, et apporter le formulaire d&#039;\u00e9valuation m\u00e9dicale \u00e0 votre m\u00e9decin pour une \u00e9valuation m\u00e9dicale. La participation \u00e0 un programme de formation en plong\u00e9e n\u00e9cessite une \u00e9valuation et l&#039;approbation de votre m\u00e9decin.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_52.1' id='input_7_52_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_7_52_1' >J'accepte d'avoir r\u00e9pondu \u00e0 toutes les questions. Si vous avez r\u00e9pondu OUI \u00e0 l'une des questions pr\u00e9c\u00e9dentes, <a href=\"https:\/\/tossadivers.com\/wp-content\/uploads\/2023\/02\/cuestionario-medico-TossaDivers.pdf\" target=\"_blank\">t\u00e9l\u00e9chargez le Questionnaire M\u00e9dical<\/a> et apportez-le au m\u00e9decin pour qu'il soit autoris\u00e9 \u00e0 pratiquer des activit\u00e9s sous-marines.<\/label><input type='hidden' name='input_52.2' value='J&#039;accepte d&#039;avoir r\u00e9pondu \u00e0 toutes les questions. Si vous avez r\u00e9pondu OUI \u00e0 l&#039;une des questions pr\u00e9c\u00e9dentes, &lt;a href=&quot;https:\/\/tossadivers.com\/wp-content\/uploads\/2023\/02\/cuestionario-medico-TossaDivers.pdf&quot; target=&quot;_blank&quot;&gt;t\u00e9l\u00e9chargez le Questionnaire M\u00e9dical&lt;\/a&gt; et apportez-le au m\u00e9decin pour qu&#039;il soit autoris\u00e9 \u00e0 pratiquer des activit\u00e9s sous-marines.' class='gform_hidden' \/><input type='hidden' name='input_52.3' value='7' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_7_53\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_53\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >D\u00e9claration du participant : J&#039;ai r\u00e9pondu honn\u00eatement \u00e0 toutes les questions et je comprends que j&#039;accepte la responsabilit\u00e9 de toute cons\u00e9quence r\u00e9sultant de toute question \u00e0 laquelle j&#039;ai pu r\u00e9pondre de mani\u00e8re inexacte ou de l&#039;omission de divulguer tout probl\u00e8me de sant\u00e9 existant ou pass\u00e9.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_53.1' id='input_7_53_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_7_53_1' >J'ai lu et j'accepte la d\u00e9claration du participant<\/label><input type='hidden' name='input_53.2' value='J&#039;ai lu et j&#039;accepte la d\u00e9claration du participant' class='gform_hidden' \/><input type='hidden' name='input_53.3' value='7' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_7_62\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full firma field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_62\" ><label class='gfield_label gform-field-label' for='input_7_62'>Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_7_62_Container' class='gfield_signature_container ginput_container' style='height:180px; width:400px; ' ><input type='hidden' class='gform_hidden' name='input_7_62_valid' id='input_7_62_valid' \/><canvas id='input_7_62' width='400' height='180' style='border-style: Dashed; border-width: 2px; border-color: #003370; background-color:#FFFFFF; cursor: url(https:\/\/tossadivers.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_7_62_toolbar' style='margin:5px 0;position:relative;height:20px;width:400px;max-width:100%;'><img decoding=\"async\" id=\"input_7_62_resetbutton\" src=\"data:image\/png;base64,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\" style=\"cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent\" alt=\"Clear Signature\" title=\"\"><\/div><input type='hidden' id='input_7_62_data' name='input_7_62_data' value=''><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_7_81' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_7_81' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' value='Suivant '  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_3' class='gform_page' data-js='page-field-id-81' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_7_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_7_80\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_80\" ><legend class='gfield_label gform-field-label' >Certification<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_80'>\n\t\t\t<div class='gchoice gchoice_7_80_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Open Water'  id='choice_7_80_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_80_0' id='label_7_80_0' class='gform-field-label gform-field-label--type-inline'>Open Water<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_80_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Advanced'  id='choice_7_80_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_80_1' id='label_7_80_1' class='gform-field-label gform-field-label--type-inline'>Advanced<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_80_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Rescue'  id='choice_7_80_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_80_2' id='label_7_80_2' class='gform-field-label gform-field-label--type-inline'>Rescue<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_80_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Divemaster'  id='choice_7_80_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_80_3' id='label_7_80_3' class='gform-field-label gform-field-label--type-inline'>Divemaster<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_80_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Instructor'  id='choice_7_80_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_80_4' id='label_7_80_4' class='gform-field-label gform-field-label--type-inline'>Instructor<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_80_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='gf_other_choice'  id='choice_7_80_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_80_5' id='label_7_80_5' class='gform-field-label gform-field-label--type-inline'>Autre<\/label><br \/><input id='input_7_80_other' class='gchoice_other_control' name='input_80_other' type='text' value='Autre' aria-label='Autre choix, veuillez sp\u00e9cifier'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_82\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_82\" ><label class='gfield_label gform-field-label' for='gform_browse_button_7_82'>Joindre la certification, l&#039;assurance et le certificat m\u00e9dical<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_7_82' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_7_82&quot;,&quot;container&quot;:&quot;gform_multifile_upload_7_82&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_7_82&quot;,&quot;filelist&quot;:&quot;gform_preview_7_82&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/tossadivers.com\\\/fr\\\/?gf_page=497dfc424655bbd&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/tossadivers.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/tossadivers.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Fichiers autoris\\u00e9s&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;134217728b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:7,&quot;field_id&quot;:82},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_7_82&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_7_82' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>D\u00e9posez les fichiers ici ou <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_7_82' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_7_82\"  >S\u00e9lectionnez des fichiers<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_7_82'>Taille max. des fichiers\u00a0: 128 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_7_82'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_7_82' class='ginput_preview_list'><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_7_83' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_7_83' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' value='Suivant '  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_4' class='gform_page' data-js='page-field-id-83' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_7_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_7_91\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_91\" ><label class='gfield_label gform-field-label' for='input_7_91'>Dispones de seguro?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_91' id='input_7_91' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='No' >No<\/option><option value='Si' >Si<\/option><\/select><\/div><\/div><div id=\"field_7_92\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_92\" ><label class='gfield_label gform-field-label' for='input_7_92'>Fecha de naciemiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_92' id='input_7_92' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='jj\/mm\/aaaa' aria-describedby=\"input_7_92_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_7_92_date_format' class='screen-reader-text'>JJ slash MM slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_92' class='gform_hidden' value='https:\/\/tossadivers.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_7_88\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_88\" ><label class='gfield_label gform-field-label' for='input_7_88'>Compa\u00f1\u00eda del seguro<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_88' id='input_7_88' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_89\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_89\" ><label class='gfield_label gform-field-label' for='input_7_89'>Fecha de caducidad del seguro<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_89' id='input_7_89' type='text' value='19\/04\/2025' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='jj\/mm\/aaaa' aria-describedby=\"input_7_89_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_7_89_date_format' class='screen-reader-text'>JJ slash MM slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_89' class='gform_hidden' value='https:\/\/tossadivers.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_7_90\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_90\" ><label class='gfield_label gform-field-label' for='input_7_90'>Adjunta captura del seguro<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='134217728' \/><input name='input_90' id='input_7_90' type='file' class='large' aria-describedby=\"gfield_upload_rules_7_90\" onchange='javascript:gformValidateFileSize( this, 134217728 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_7_90'>Taille max. des fichiers\u00a0: 128 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_7_90'><\/div><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_7_86' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' value='Anterior'  \/> <input type='button' id='gform_next_button_7_86' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' value='Siguiente '  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_5' class='gform_page' data-js='page-field-id-86' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_7_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_7_93\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_7_93\" ><legend class='gfield_label 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