{"id":93,"date":"2019-01-19T22:46:25","date_gmt":"2019-01-19T22:46:25","guid":{"rendered":"http:\/\/myologyworks.com\/?page_id=93"},"modified":"2021-09-21T19:17:06","modified_gmt":"2021-09-21T19:17:06","slug":"adult-intake-form","status":"publish","type":"page","link":"https:\/\/myologyworks.com\/index.php\/adult-intake-form\/","title":{"rendered":"Adult Intake Form"},"content":{"rendered":"<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-92\"><form id=\"wpforms-form-92\" class=\"wpforms-validate wpforms-form\" data-formid=\"92\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/93\" data-token=\"701ee998435c78b1eb1c6799a01dd945\" data-token-time=\"1793007930\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-92-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><label class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-92-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" required><label for=\"wpforms-92-field_0\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-92-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" required><label for=\"wpforms-92-field_0-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-92-field_23-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-92-field_23\">Phone Number <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-92-field_23\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][23]\" required><\/div><div id=\"wpforms-92-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-92-field_3\">Address <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-92-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" required><\/div><div id=\"wpforms-92-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-92-field_1\">Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-92-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-92-field_4-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"4\"><label class=\"wpforms-field-label\">Do you usually breathe through your mouth?<\/label><ul id=\"wpforms-92-field_4\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_4_1\" name=\"wpforms[fields][4][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_4_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_4_2\" name=\"wpforms[fields][4][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_4_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-92-field_18-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"18\"><label class=\"wpforms-field-label\">Do you snore while sleeping?<\/label><ul id=\"wpforms-92-field_18\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_18_1\" name=\"wpforms[fields][18][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_18_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_18_2\" name=\"wpforms[fields][18][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_18_2\">No<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_18_3\" name=\"wpforms[fields][18][]\" value=\"Don&#039;t Know\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_18_3\">Don't Know<\/label><\/li><\/ul><\/div><div id=\"wpforms-92-field_17-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"17\"><label class=\"wpforms-field-label\">Do you stop or pause your breathing while sleeping?<\/label><ul id=\"wpforms-92-field_17\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_17_1\" name=\"wpforms[fields][17][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_17_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_17_2\" name=\"wpforms[fields][17][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_17_2\">No<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_17_3\" name=\"wpforms[fields][17][]\" value=\"Don&#039;t Know\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_17_3\">Don't Know<\/label><\/li><\/ul><\/div><div id=\"wpforms-92-field_16-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"16\"><label class=\"wpforms-field-label\">Do you easily get tired or fall asleep during the day?<\/label><ul id=\"wpforms-92-field_16\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_16_1\" name=\"wpforms[fields][16][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_16_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_16_2\" name=\"wpforms[fields][16][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_16_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-92-field_15-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"15\"><label class=\"wpforms-field-label\">Do you use sleep medication?<\/label><ul id=\"wpforms-92-field_15\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_15_1\" name=\"wpforms[fields][15][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_15_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_15_2\" name=\"wpforms[fields][15][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_15_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-92-field_14-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"14\"><label class=\"wpforms-field-label\">Do you have any facial pain?<\/label><ul id=\"wpforms-92-field_14\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_14_1\" name=\"wpforms[fields][14][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_14_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_14_2\" name=\"wpforms[fields][14][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_14_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-92-field_13-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"13\"><label class=\"wpforms-field-label\">Do you have difficulty opening or closing your mouth or while chewing?<\/label><ul id=\"wpforms-92-field_13\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_13_1\" name=\"wpforms[fields][13][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_13_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_13_2\" name=\"wpforms[fields][13][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_13_2\">No<\/label><\/li><\/ul><\/div>\t\t<div id=\"wpforms-92-field_22-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"22\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-92-field_22\" >during Name the<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-92-field_22\" class=\"wpforms-field-medium\" name=\"wpforms[fields][22]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-92-field_12-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"12\"><label class=\"wpforms-field-label\">Do you clench or grind your teeth during the day or night?<\/label><ul id=\"wpforms-92-field_12\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_12_1\" name=\"wpforms[fields][12][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_12_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_12_2\" name=\"wpforms[fields][12][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_12_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-92-field_11-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"11\"><label class=\"wpforms-field-label\">Do your gums bleed?<\/label><ul id=\"wpforms-92-field_11\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_11_1\" name=\"wpforms[fields][11][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_11_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_11_2\" name=\"wpforms[fields][11][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_11_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-92-field_10-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"10\"><label class=\"wpforms-field-label\">Is your pillow wet in the morning?<\/label><ul id=\"wpforms-92-field_10\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_10_1\" name=\"wpforms[fields][10][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_10_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_10_2\" name=\"wpforms[fields][10][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_10_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-92-field_9-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"9\"><label class=\"wpforms-field-label\">Do you keep your mouth open while watching TV or using the computer?<\/label><ul id=\"wpforms-92-field_9\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_9_1\" name=\"wpforms[fields][9][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_9_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_9_2\" name=\"wpforms[fields][9][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_9_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-92-field_8-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"8\"><label class=\"wpforms-field-label\">Do you easily catch colds?<\/label><ul id=\"wpforms-92-field_8\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_8_1\" name=\"wpforms[fields][8][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_8_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_8_2\" name=\"wpforms[fields][8][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_8_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-92-field_7-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"7\"><label class=\"wpforms-field-label\">Do you have allergies?<\/label><ul id=\"wpforms-92-field_7\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_7_1\" name=\"wpforms[fields][7][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_7_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_7_2\" name=\"wpforms[fields][7][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_7_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-92-field_6-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"6\"><label class=\"wpforms-field-label\">Do you have a history of the following:<\/label><ul id=\"wpforms-92-field_6\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_6_1\" name=\"wpforms[fields][6][]\" value=\"Thumb sucking\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_6_1\">Thumb sucking<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_6_2\" name=\"wpforms[fields][6][]\" value=\"Finger sucking\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_6_2\">Finger sucking<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_6_3\" name=\"wpforms[fields][6][]\" value=\"Tongue sucking\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_6_3\">Tongue sucking<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_6_4\" name=\"wpforms[fields][6][]\" value=\"Nail bitting\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_6_4\">Nail bitting<\/label><\/li><\/ul><\/div><div id=\"wpforms-92-field_5-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"5\"><label class=\"wpforms-field-label\">Do you have difficulty pronouncing sounds?<\/label><ul id=\"wpforms-92-field_5\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_5_1\" name=\"wpforms[fields][5][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_5_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-92-field_5_2\" name=\"wpforms[fields][5][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-92-field_5_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-92-field_21-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-92-field_21\">What do you hope to achieve from this evaluation?<\/label><textarea id=\"wpforms-92-field_21\" class=\"wpforms-field-medium\" name=\"wpforms[fields][21]\" ><\/textarea><\/div><div id=\"wpforms-92-field_20-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-92-field_20\">Describe the problem you\u2019re experiencing<\/label><textarea id=\"wpforms-92-field_20\" class=\"wpforms-field-medium\" name=\"wpforms[fields][20]\" ><\/textarea><\/div><div id=\"wpforms-92-field_19-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-92-field_19\">What do you think caused the problem?<\/label><textarea id=\"wpforms-92-field_19\" class=\"wpforms-field-medium\" name=\"wpforms[fields][19]\" ><\/textarea><\/div><div id=\"wpforms-92-field_2-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-92-field_2\">What have you tried to fix the problem?<\/label><textarea id=\"wpforms-92-field_2\" class=\"wpforms-field-medium\" name=\"wpforms[fields][2]\" ><\/textarea><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-92-field_22-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-92-field_22-container input { visibility: hidden; } #wpforms-conversational-form-page #wpforms-92-field_22-container label { counter-increment: none; }' ) );\n\t\t\t\t\tdocument.head.appendChild( style );\n\t\t\t\t\tdocument.currentScript?.remove();\n\t\t\t\t} )();\n\t\t\t<\/script><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"92\"><input type=\"hidden\" name=\"wpforms[time_token]\" value=\"1793007930.e6a1f5a5ed0fd2ce8ffd600772d5627da9c66c2f1c1ded996432d484563d4915\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/myologyworks.com\/index.php\/wp-json\/wp\/v2\/pages\/93\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-92\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><\/div><\/form><\/div>  <!-- .wpforms-container -->\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-93","page","type-page","status-publish","hentry"],"jetpack_sharing_enabled":true,"jetpack_shortlink":"https:\/\/wp.me\/PaDvrU-1v","_links":{"self":[{"href":"https:\/\/myologyworks.com\/index.php\/wp-json\/wp\/v2\/pages\/93","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/myologyworks.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/myologyworks.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/myologyworks.com\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/myologyworks.com\/index.php\/wp-json\/wp\/v2\/comments?post=93"}],"version-history":[{"count":2,"href":"https:\/\/myologyworks.com\/index.php\/wp-json\/wp\/v2\/pages\/93\/revisions"}],"predecessor-version":[{"id":330,"href":"https:\/\/myologyworks.com\/index.php\/wp-json\/wp\/v2\/pages\/93\/revisions\/330"}],"wp:attachment":[{"href":"https:\/\/myologyworks.com\/index.php\/wp-json\/wp\/v2\/media?parent=93"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}