{"id":869,"date":"2021-04-06T17:06:10","date_gmt":"2021-04-06T17:06:10","guid":{"rendered":"https:\/\/gloucesterchiropractic.co.uk\/?page_id=869"},"modified":"2021-11-02T11:38:17","modified_gmt":"2021-11-02T11:38:17","slug":"chiropractic-health-assessment","status":"publish","type":"page","link":"https:\/\/gloucesterchiropractic.co.uk\/chiropractic-health-assessment\/","title":{"rendered":"Chiropractic Health Assessment"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"869\" class=\"elementor elementor-869\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-76bba73 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"76bba73\" data-element_type=\"section\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[{&quot;jet_parallax_layout_image&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;,&quot;size&quot;:&quot;&quot;},&quot;_id&quot;:&quot;f34ede7&quot;,&quot;jet_parallax_layout_image_tablet&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;,&quot;size&quot;:&quot;&quot;},&quot;jet_parallax_layout_image_mobile&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;,&quot;size&quot;:&quot;&quot;},&quot;jet_parallax_layout_speed&quot;:{&quot;unit&quot;:&quot;%&quot;,&quot;size&quot;:50,&quot;sizes&quot;:[]},&quot;jet_parallax_layout_type&quot;:&quot;scroll&quot;,&quot;jet_parallax_layout_direction&quot;:null,&quot;jet_parallax_layout_fx_direction&quot;:null,&quot;jet_parallax_layout_z_index&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_x&quot;:50,&quot;jet_parallax_layout_bg_x_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_x_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_y&quot;:50,&quot;jet_parallax_layout_bg_y_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_y_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_size&quot;:&quot;auto&quot;,&quot;jet_parallax_layout_bg_size_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_size_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_animation_prop&quot;:&quot;transform&quot;,&quot;jet_parallax_layout_on&quot;:[&quot;desktop&quot;,&quot;tablet&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-d95374c\" data-id=\"d95374c\" 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-21a6d05 elementor-widget elementor-widget-text-editor\" data-id=\"21a6d05\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\tFind out how we can help you\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-0fcddda elementor-widget elementor-widget-heading\" data-id=\"0fcddda\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Chiropractic Health Assessment<\/h1>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-be469cf elementor-widget elementor-widget-text-editor\" data-id=\"be469cf\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<p>If you are not sure if we could help you and you would like to find out if we could, then please complete this short questionnaire. Liz or Nick will review it with 24hrs and respond personally regarding your condition and how we can help.<\/p><p>As every patient&#8217;s injuries are unique, we may recommend an initial consultation. Prefer to talk to us? Book a phone call appointment here.<\/p>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-0e69c6d elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"0e69c6d\" data-element_type=\"section\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[{&quot;jet_parallax_layout_image&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;,&quot;size&quot;:&quot;&quot;},&quot;_id&quot;:&quot;987818d&quot;,&quot;jet_parallax_layout_image_tablet&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;,&quot;size&quot;:&quot;&quot;},&quot;jet_parallax_layout_image_mobile&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;,&quot;size&quot;:&quot;&quot;},&quot;jet_parallax_layout_speed&quot;:{&quot;unit&quot;:&quot;%&quot;,&quot;size&quot;:50,&quot;sizes&quot;:[]},&quot;jet_parallax_layout_type&quot;:&quot;scroll&quot;,&quot;jet_parallax_layout_direction&quot;:null,&quot;jet_parallax_layout_fx_direction&quot;:null,&quot;jet_parallax_layout_z_index&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_x&quot;:50,&quot;jet_parallax_layout_bg_x_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_x_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_y&quot;:50,&quot;jet_parallax_layout_bg_y_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_y_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_size&quot;:&quot;auto&quot;,&quot;jet_parallax_layout_bg_size_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_size_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_animation_prop&quot;:&quot;transform&quot;,&quot;jet_parallax_layout_on&quot;:[&quot;desktop&quot;,&quot;tablet&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-da423f5\" data-id=\"da423f5\" 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-8c6d862 elementor-button-align-start elementor-widget elementor-widget-form\" data-id=\"8c6d862\" data-element_type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;button_width&quot;:&quot;100&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"New Form\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"869\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"8c6d862\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"\" \/>\n\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-name elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFirst Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[name]\" id=\"form-field-name\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_bc9d425 elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_bc9d425\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLast Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_bc9d425]\" id=\"form-field-field_bc9d425\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-email elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-email\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmail\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[email]\" id=\"form-field-email\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_8ae4758 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8ae4758\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_8ae4758]\" id=\"form-field-field_8ae4758\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_48f60be elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_48f60be\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you received chiropractic treatment before?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_48f60be-0\" name=\"form_fields[field_48f60be]\"> <label for=\"form-field-field_48f60be-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_48f60be-1\" name=\"form_fields[field_48f60be]\"> <label for=\"form-field-field_48f60be-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_ca17c80 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ca17c80\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWhere is your pain?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Back\" id=\"form-field-field_ca17c80-0\" name=\"form_fields[field_ca17c80][]\"> <label for=\"form-field-field_ca17c80-0\">Back<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Legs\/leg\" id=\"form-field-field_ca17c80-1\" name=\"form_fields[field_ca17c80][]\"> <label for=\"form-field-field_ca17c80-1\">Legs\/leg<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Hip\" id=\"form-field-field_ca17c80-2\" name=\"form_fields[field_ca17c80][]\"> <label for=\"form-field-field_ca17c80-2\">Hip<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Knees\" id=\"form-field-field_ca17c80-3\" name=\"form_fields[field_ca17c80][]\"> <label for=\"form-field-field_ca17c80-3\">Knees<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Ankles\/feet\" id=\"form-field-field_ca17c80-4\" name=\"form_fields[field_ca17c80][]\"> <label for=\"form-field-field_ca17c80-4\">Ankles\/feet<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Neck\" id=\"form-field-field_ca17c80-5\" name=\"form_fields[field_ca17c80][]\"> <label for=\"form-field-field_ca17c80-5\">Neck<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Arms\/arm\" id=\"form-field-field_ca17c80-6\" name=\"form_fields[field_ca17c80][]\"> <label for=\"form-field-field_ca17c80-6\">Arms\/arm<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Shoulder\" id=\"form-field-field_ca17c80-7\" name=\"form_fields[field_ca17c80][]\"> <label for=\"form-field-field_ca17c80-7\">Shoulder<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Elbow\" id=\"form-field-field_ca17c80-8\" name=\"form_fields[field_ca17c80][]\"> <label for=\"form-field-field_ca17c80-8\">Elbow<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Wrist\/hand\" id=\"form-field-field_ca17c80-9\" name=\"form_fields[field_ca17c80][]\"> <label for=\"form-field-field_ca17c80-9\">Wrist\/hand<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Headaches\" id=\"form-field-field_ca17c80-10\" name=\"form_fields[field_ca17c80][]\"> <label for=\"form-field-field_ca17c80-10\">Headaches<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Migraines\" id=\"form-field-field_ca17c80-11\" name=\"form_fields[field_ca17c80][]\"> <label for=\"form-field-field_ca17c80-11\">Migraines<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Multiple areas of the body\" id=\"form-field-field_ca17c80-12\" name=\"form_fields[field_ca17c80][]\"> <label for=\"form-field-field_ca17c80-12\">Multiple areas of the body<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Other\" id=\"form-field-field_ca17c80-13\" name=\"form_fields[field_ca17c80][]\"> <label for=\"form-field-field_ca17c80-13\">Other<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_5fd31f3 elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5fd31f3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlease Rate your pain from 0 - 10\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_5fd31f3]\" id=\"form-field-field_5fd31f3\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select...\">Select...<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">0<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">1<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">2<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3\">3<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4\">4<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"5\">5<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"6\">6<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"7\">7<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"8\">8<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"9\">9<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"10\">10<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_0c6504d elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0c6504d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo  you have any other symptoms?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_0c6504d]\" id=\"form-field-field_0c6504d\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select...\">Select...<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Stiffness\">Stiffness<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Burning\">Burning<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Pins &amp; needles\">Pins &amp; needles<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Numbness\">Numbness<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_49c051f elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_49c051f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHow long have you had these symptoms?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_49c051f]\" id=\"form-field-field_49c051f\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t<option value=\"Select...\">Select...<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Less than 1 week\">Less than 1 week<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1 -  4 weeks\">1 -  4 weeks<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1 - 6 months\">1 - 6 months<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"6 - 12 months\">6 - 12 months<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1 - 4 years\">1 - 4 years<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"5 - 10 years\">5 - 10 years<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"10 - 15 years\">10 - 15 years<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_fd09513 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_fd09513\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWhat eases your symptoms?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Rest\" id=\"form-field-field_fd09513-0\" name=\"form_fields[field_fd09513][]\"> <label for=\"form-field-field_fd09513-0\">Rest<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Ice\" id=\"form-field-field_fd09513-1\" name=\"form_fields[field_fd09513][]\"> <label for=\"form-field-field_fd09513-1\">Ice<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Massage\" id=\"form-field-field_fd09513-2\" name=\"form_fields[field_fd09513][]\"> <label for=\"form-field-field_fd09513-2\">Massage<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Stretches\" id=\"form-field-field_fd09513-3\" name=\"form_fields[field_fd09513][]\"> <label for=\"form-field-field_fd09513-3\">Stretches<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Walking\" id=\"form-field-field_fd09513-4\" name=\"form_fields[field_fd09513][]\"> <label for=\"form-field-field_fd09513-4\">Walking<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Pain killers\" id=\"form-field-field_fd09513-5\" name=\"form_fields[field_fd09513][]\"> <label for=\"form-field-field_fd09513-5\">Pain killers<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Other\" id=\"form-field-field_fd09513-6\" name=\"form_fields[field_fd09513][]\"> <label for=\"form-field-field_fd09513-6\">Other<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_77757f1 elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_77757f1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you experienced these symptoms or similar before? If yes we will ask more about this during your consultation\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_77757f1-0\" name=\"form_fields[field_77757f1]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_77757f1-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_77757f1-1\" name=\"form_fields[field_77757f1]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_77757f1-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_864b877 elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_864b877\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you had any accidents \/ falls \/ broken bones? If yes, we will ask you about this at your consultation.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_864b877-0\" name=\"form_fields[field_864b877]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_864b877-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_864b877-1\" name=\"form_fields[field_864b877]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_864b877-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_1b199b9 elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1b199b9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you had any serious illnesses, operations, or disabilities? If yes, we will ask you about this at your consultation.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_1b199b9-0\" name=\"form_fields[field_1b199b9]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_1b199b9-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_1b199b9-1\" name=\"form_fields[field_1b199b9]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_1b199b9-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-message elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-message\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlease include any additional relevant information you think we should know below.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[message]\" id=\"form-field-message\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-field_9133367 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[field_9133367]\" id=\"form-field-field_9133367\" class=\"elementor-field elementor-size-sm  elementor-acceptance-field\" required=\"required\" aria-required=\"true\">\n\t\t\t\t<label for=\"form-field-field_9133367\">I consent to Posture Right Chiropractors keeping my data secure as per their privacy policy.<\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-recaptcha_v3 elementor-field-group elementor-column elementor-field-group-field_d849c58 elementor-col-100 recaptcha_v3-bottomright\">\n\t\t\t\t\t<div class=\"elementor-field\" id=\"form-field-field_d849c58\"><div class=\"elementor-g-recaptcha\" data-sitekey=\"6Leg4UIcAAAAAIjWFkTbj78eKQ4dcpyUImCbXm9K\" data-type=\"v3\" data-action=\"Form\" data-badge=\"bottomright\" data-size=\"invisible\"><\/div><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button type=\"submit\" class=\"elementor-button elementor-size-sm\">\n\t\t\t\t\t\t<span >\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\" elementor-button-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Submit Assessment<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Find out how we can help you Chiropractic Health Assessment If you are not sure if we could help you and you would like to find out if we could, then please complete this short questionnaire. Liz or Nick will review it with 24hrs and respond personally regarding your condition and how we can help. [&hellip;]<\/p>\n","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":14,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"acf":[],"_links":{"self":[{"href":"https:\/\/gloucesterchiropractic.co.uk\/wp-json\/wp\/v2\/pages\/869"}],"collection":[{"href":"https:\/\/gloucesterchiropractic.co.uk\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/gloucesterchiropractic.co.uk\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/gloucesterchiropractic.co.uk\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/gloucesterchiropractic.co.uk\/wp-json\/wp\/v2\/comments?post=869"}],"version-history":[{"count":5,"href":"https:\/\/gloucesterchiropractic.co.uk\/wp-json\/wp\/v2\/pages\/869\/revisions"}],"predecessor-version":[{"id":941,"href":"https:\/\/gloucesterchiropractic.co.uk\/wp-json\/wp\/v2\/pages\/869\/revisions\/941"}],"wp:attachment":[{"href":"https:\/\/gloucesterchiropractic.co.uk\/wp-json\/wp\/v2\/media?parent=869"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}