{"id":900,"date":"2026-03-19T07:58:47","date_gmt":"2026-03-19T07:58:47","guid":{"rendered":"https:\/\/audiologyassessment.co.uk\/?page_id=900"},"modified":"2026-03-26T08:06:07","modified_gmt":"2026-03-26T08:06:07","slug":"audiology-assessment","status":"publish","type":"page","link":"https:\/\/audiologyassessment.co.uk\/","title":{"rendered":"assessment"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"900\" class=\"elementor elementor-900\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-9557971 e-con-full e-flex e-con e-parent\" data-id=\"9557971\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-942b11c e-con-full e-flex e-con e-child\" data-id=\"942b11c\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-ff01b9e elementor-widget elementor-widget-heading\" data-id=\"ff01b9e\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Audiology Assessment<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-9b54cbd elementor-widget elementor-widget-text-editor\" data-id=\"9b54cbd\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>Clinical pre\u2011assessment for independent audiology clinics<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-0e3e913 elementor-widget elementor-widget-text-editor\" data-id=\"0e3e913\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>A structured intake process that gathers essential information, reviews your case, and prepares it for a qualified local audiologist.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-b51c6e5 elementor-widget elementor-widget-button\" data-id=\"b51c6e5\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t\t\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm elementor-animation-grow\" href=\"#assessment-form\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Start Assessment<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-b648266 e-flex e-con-boxed e-con e-parent\" data-id=\"b648266\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-aec0f6f elementor-widget elementor-widget-heading\" data-id=\"aec0f6f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Professional Triage for Tinnitus and Sudden Hearing Changes in Hampshire.<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-160a2a6 elementor-widget elementor-widget-heading\" data-id=\"160a2a6\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h3 class=\"elementor-heading-title elementor-size-default\">We work with independent audiologists across Winchester and surrounding areas<\/h3>\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-6f5bd9f e-grid e-con-boxed e-con e-parent\" data-id=\"6f5bd9f\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-aae66bc e-con-full e-flex e-con e-child\" data-id=\"aae66bc\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-9691fa4 elementor-widget elementor-widget-heading\" data-id=\"9691fa4\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Step 1 \u2014 Submit your details<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-ca85e0f elementor-widget__width-initial elementor-widget elementor-widget-text-editor\" data-id=\"ca85e0f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>Provide a brief outline of your symptoms, history, and any previous hearing tests. Your information will only be used to process your assessment.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-74b7154 e-con-full e-flex e-con e-child\" data-id=\"74b7154\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-966705d elementor-widget elementor-widget-heading\" data-id=\"966705d\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Step 2 \u2014 We review your case <\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-0451db8 elementor-widget__width-initial elementor-widget elementor-widget-text-editor\" data-id=\"0451db8\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>A structured pre\u2011assessment checks for red flags, missing information, and suitability for audiological investigation.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-4a0681c e-con-full e-flex e-con e-child\" data-id=\"4a0681c\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-c29680c elementor-widget elementor-widget-heading\" data-id=\"c29680c\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Step 3 \u2014 Prepared for an audiologist  <\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-88c9f1e elementor-widget__width-initial elementor-widget elementor-widget-text-editor\" data-id=\"88c9f1e\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>Fully triaged complete cases are escalated to an independent audiology clinic, who will contact you to book an appropriate date and time based on clinical need.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-2ca2ef6 e-flex e-con-boxed e-con e-parent\" data-id=\"2ca2ef6\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-41ca997 elementor-widget elementor-widget-heading\" data-id=\"41ca997\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h3 class=\"elementor-heading-title elementor-size-default\">Before you begin<\/h3>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-2547e19 elementor-widget__width-initial elementor-widget elementor-widget-text-editor\" data-id=\"2547e19\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>This pre\u2011assessment helps us understand your hearing concerns, medical history, and any previous tests. It takes around 5 minutes to complete.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-6f4743d e-flex e-con-boxed e-con e-parent\" data-id=\"6f4743d\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-d4205bc fluent-form-widget-step-header-yes fluent-form-widget-step-progressbar-yes fluentform-widget-submit-button-custom elementor-widget elementor-widget-fluent-form-widget\" data-id=\"d4205bc\" data-element_type=\"widget\" data-e-type=\"widget\" id=\"assessment-form\" data-widget_type=\"fluent-form-widget.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\n            <div class=\"fluentform-widget-wrapper fluentform-widget-align-default\">\n\n            \n            <div class='fluentform ff-default fluentform_wrapper_3 ffs_default_wrap'><form data-form_id=\"3\" id=\"fluentform_3\" class=\"frm-fluent-form fluent_form_3 ff-el-form-top ff_form_instance_3_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_3_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Audiology Intake<\/legend>        <div\n                style=\"display: none!important; position: absolute!important; transform: translateX(1000%)!important;\"\n                class=\"ff-el-group ff-hpsf-container\"\n        >\n            <div class=\"ff-el-input--label asterisk-right\">\n                <label for=\"ff_3_item_sf\" aria-label=\"Newsletter\">\n                    Newsletter                <\/label>\n            <\/div>\n            <div class=\"ff-el-input--content\">\n                <input type=\"text\"\n                       name=\"item_3__fluent_sf\"\n                       class=\"ff-el-form-control\"\n                       id=\"ff_3_item_sf\"\n                \/>\n            <\/div>\n        <\/div>\n        <input type='hidden' name='__fluent_form_embded_post_id' value='900' \/><input type=\"hidden\" id=\"_fluentform_3_fluentformnonce\" name=\"_fluentform_3_fluentformnonce\" value=\"dbfd603cbf\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php\/wp-json\/wp\/v2\/pages\/900\" \/><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_1\" ><h3 style=\"text-align: center\">Personal Details<\/h3>\n<p style=\"text-align: center\"><em>So we know who we\u2019re helping<\/em><\/p><\/div><div data-type=\"name-element\" data-name=\"names\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_names_first_name_' id='label_ff_3_names_first_name_' >First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_3_names_first_name_\" class=\"ff-el-form-control\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_names_last_name_' id='label_ff_3_names_last_name_' >Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[last_name]\" id=\"ff_3_names_last_name_\" class=\"ff-el-form-control\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_email' id='label_ff_3_email' aria-label=\"Email\">Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" id=\"ff_3_email\" class=\"ff-el-form-control\" data-name=\"email\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text' id='label_ff_3_input_text' aria-label=\"Phone Number\">Phone Number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" data-name=\"input_text\" id=\"ff_3_input_text\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50.19%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_1' id='label_ff_3_input_text_1' aria-label=\"Postal Code\">Postal Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" data-name=\"input_text_1\" id=\"ff_3_input_text_1\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 49.81%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Preferred contact method\"> Preferred contact method<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_18b9eb2a6c15929336e278bbd58ea2ae'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Phone\"  id='input_radio_18b9eb2a6c15929336e278bbd58ea2ae' aria-label='Phone' aria-invalid='false' aria-required=true> <span>Phone<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_f5a11968348a7ab490a3f2cb17bfd234'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Email\"  id='input_radio_f5a11968348a7ab490a3f2cb17bfd234' aria-label='Email' aria-invalid='false' aria-required=true> <span>Email<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_2\" ><h3 style=\"text-align: center\">Your Hearing Concerns<\/h3>\n<p style=\"text-align: center;letter-spacing: 0.5px\"><em> Tell us what\u2019s been happening recently<br \/>Please tick all that apply<\/em><\/p><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_1 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Sudden Change\">Sudden Change<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='Sudden_Change_13f6b4bf07d4ffe7f53422559ef3ad6c'><input  type=\"checkbox\" name=\"Sudden_Change[]\" data-name=\"Sudden_Change\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"I\u2019ve had a sudden change in my hearing\" data-calc_value=\"1\"  id='Sudden_Change_13f6b4bf07d4ffe7f53422559ef3ad6c' aria-label='I\u2019ve had a sudden change in my hearing' aria-invalid='false' aria-required=false> <span>I\u2019ve had a sudden change in my hearing<\/span><\/label><\/div><\/div><\/div><div class=\"has-conditions  ff-field_container ff-chained-select-field-wrapper\" data-type=\"chained-select\" data-name=\"sudden_change_list\" data-source-type=\"file\" ><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_sudden_change_list_Which_ear?_' id='label_ff_3_sudden_change_list_Which_ear?_' aria-label=\"Which ear?\">Which ear?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"sudden_change_list[Which ear?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"sudden_change_list\" data-source-type=\"file\" id=\"ff_3_sudden_change_list_Which_ear?_\" data-index=\"0\" data-meta_key=\"chained_select_sudden_change_list\" data-key=\"Which ear?\" ><option value=''>Which ear?<\/option><option value='Left ear'>Left ear<\/option><option value='Right ear'>Right ear<\/option><option value='Both ears'>Both ears<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_sudden_change_list_When_did_this_start?_' id='label_ff_3_sudden_change_list_When_did_this_start?_' aria-label=\"When did this start?\">When did this start?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"sudden_change_list[When did this start?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"sudden_change_list\" data-source-type=\"file\" id=\"ff_3_sudden_change_list_When_did_this_start?_\" data-index=\"1\" data-meta_key=\"chained_select_sudden_change_list\" data-key=\"When did this start?\" ><option value=''>When did this start?<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_sudden_change_list_What_does_it_feel_like?_' id='label_ff_3_sudden_change_list_What_does_it_feel_like?_' aria-label=\"What does it feel like?\">What does it feel like?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"sudden_change_list[What does it feel like?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"sudden_change_list\" data-source-type=\"file\" id=\"ff_3_sudden_change_list_What_does_it_feel_like?_\" data-index=\"2\" data-meta_key=\"chained_select_sudden_change_list\" data-key=\"What does it feel like?\" ><option value=''>What does it feel like?<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_1 ff-hidden'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_sc_base' id='label_ff_3_sc_base' aria-label=\"sc_base\">sc_base<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"sc_base\" id=\"ff_3_sc_base\" class=\"ff-el-form-control\" data-name=\"sc_base\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_sc_onset' id='label_ff_3_sc_onset' aria-label=\"sc_onset\">sc_onset<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"sc_onset\" id=\"ff_3_sc_onset\" class=\"ff-el-form-control\" data-name=\"sc_onset\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_sc_percept' id='label_ff_3_sc_percept' aria-label=\"sc_percept\">sc_percept<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"sc_percept\" id=\"ff_3_sc_percept\" class=\"ff-el-form-control\" data-name=\"sc_percept\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_sc_context' id='label_ff_3_sc_context' aria-label=\"sc_context\">sc_context<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"sc_context\" id=\"ff_3_sc_context\" class=\"ff-el-form-control\" data-name=\"sc_context\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_sc_total' id='label_ff_3_sc_total' aria-label=\"sc_total\">sc_total<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"sc_total\" id=\"ff_3_sc_total\" class=\"ff-el-form-control\" data-name=\"sc_total\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_5\"  class='ff-t-container ff-column-container ff_columns_total_1 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Tinnitus\">Tinnitus<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='Tinnitus_eba3427cb56244a3836cf700eee42489'><input  type=\"checkbox\" name=\"Tinnitus[]\" data-name=\"Tinnitus\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"I have ringing or noises in my ears\" data-calc_value=\"1\"  id='Tinnitus_eba3427cb56244a3836cf700eee42489' aria-label='I have ringing or noises in my ears' aria-invalid='false' aria-required=false> <span>I have ringing or noises in my ears<\/span><\/label><\/div><\/div><\/div><div class=\"has-conditions  ff-field_container ff-chained-select-field-wrapper\" data-type=\"chained-select\" data-name=\"tinnitus_list\" data-source-type=\"file\" ><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_tinnitus_list_Which_ear?_' id='label_ff_3_tinnitus_list_Which_ear?_' aria-label=\"Which ear?\">Which ear?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"tinnitus_list[Which ear?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"tinnitus_list\" data-source-type=\"file\" id=\"ff_3_tinnitus_list_Which_ear?_\" data-index=\"0\" data-meta_key=\"chained_select_tinnitus_list\" data-key=\"Which ear?\" ><option value=''>Which ear?<\/option><option value='Left ear'>Left ear<\/option><option value='Right ear'>Right ear<\/option><option value='Both ears'>Both ears<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_tinnitus_list_When_did_this_start?_' id='label_ff_3_tinnitus_list_When_did_this_start?_' aria-label=\"When did this start?\">When did this start?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"tinnitus_list[When did this start?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"tinnitus_list\" data-source-type=\"file\" id=\"ff_3_tinnitus_list_When_did_this_start?_\" data-index=\"1\" data-meta_key=\"chained_select_tinnitus_list\" data-key=\"When did this start?\" ><option value=''>When did this start?<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_tinnitus_list_What_does_it_feel_like?_' id='label_ff_3_tinnitus_list_What_does_it_feel_like?_' aria-label=\"What does it feel like?\">What does it feel like?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"tinnitus_list[What does it feel like?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"tinnitus_list\" data-source-type=\"file\" id=\"ff_3_tinnitus_list_What_does_it_feel_like?_\" data-index=\"2\" data-meta_key=\"chained_select_tinnitus_list\" data-key=\"What does it feel like?\" ><option value=''>What does it feel like?<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_6\"  class='ff-t-container ff-column-container ff_columns_total_1 ff-hidden'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_tn_base' id='label_ff_3_tn_base' aria-label=\"tn_base\">tn_base<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"tn_base\" id=\"ff_3_tn_base\" class=\"ff-el-form-control\" data-name=\"tn_base\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_tn_onset' id='label_ff_3_tn_onset' aria-label=\"tn_onset\">tn_onset<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"tn_onset\" id=\"ff_3_tn_onset\" class=\"ff-el-form-control\" data-name=\"tn_onset\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_tn_percept' id='label_ff_3_tn_percept' aria-label=\"tn_percept\">tn_percept<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"tn_percept\" id=\"ff_3_tn_percept\" class=\"ff-el-form-control\" data-name=\"tn_percept\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_tn_context' id='label_ff_3_tn_context' aria-label=\"tn_context\">tn_context<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"tn_context\" id=\"ff_3_tn_context\" class=\"ff-el-form-control\" data-name=\"tn_context\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_tn_total' id='label_ff_3_tn_total' aria-label=\"tn_total\">tn_total<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"tn_total\" id=\"ff_3_tn_total\" class=\"ff-el-form-control\" data-name=\"tn_total\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_7\"  class='ff-t-container ff-column-container ff_columns_total_1 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Feeling Generally Unwell\">Feeling Generally Unwell<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='Gen_Unwell_0182cf7b80191d23d81245f0005e49ed'><input  type=\"checkbox\" name=\"Gen_Unwell[]\" data-name=\"Gen_Unwell\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"e.g. fever, severe headache, confusion)\" data-calc_value=\"1\"  id='Gen_Unwell_0182cf7b80191d23d81245f0005e49ed' aria-label='e.g. fever, severe headache, confusion' aria-invalid='false' aria-required=false> <span>e.g. fever, severe headache, confusion<\/span><\/label><\/div><\/div><\/div><div class=\"has-conditions  ff-field_container ff-chained-select-field-wrapper\" data-type=\"chained-select\" data-name=\"gen_unwell_list\" data-source-type=\"file\" ><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_gen_unwell_list_Main_symptom_' id='label_ff_3_gen_unwell_list_Main_symptom_' aria-label=\"Main symptom\">Main symptom<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"gen_unwell_list[Main symptom]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"gen_unwell_list\" data-source-type=\"file\" id=\"ff_3_gen_unwell_list_Main_symptom_\" data-index=\"0\" data-meta_key=\"chained_select_gen_unwell_list\" data-key=\"Main symptom\" ><option value=''>Main symptom<\/option><option value='Fever or chills'>Fever or chills<\/option><option value='Severe headache'>Severe headache<\/option><option value='Confusion or disorientation'>Confusion or disorientation<\/option><option value='Extreme fatigue'>Extreme fatigue<\/option><option value='Nausea or vomiting'>Nausea or vomiting<\/option><option value='Dizziness or faintness'>Dizziness or faintness<\/option><option value='Body aches'>Body aches<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_gen_unwell_list_How_long_for?_' id='label_ff_3_gen_unwell_list_How_long_for?_' aria-label=\"How long for?\">How long for?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"gen_unwell_list[How long for?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"gen_unwell_list\" data-source-type=\"file\" id=\"ff_3_gen_unwell_list_How_long_for?_\" data-index=\"1\" data-meta_key=\"chained_select_gen_unwell_list\" data-key=\"How long for?\" ><option value=''>How long for?<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_gen_unwell_list_How_severe_is_it?_' id='label_ff_3_gen_unwell_list_How_severe_is_it?_' aria-label=\"How severe is it?\">How severe is it?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"gen_unwell_list[How severe is it?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"gen_unwell_list\" data-source-type=\"file\" id=\"ff_3_gen_unwell_list_How_severe_is_it?_\" data-index=\"2\" data-meta_key=\"chained_select_gen_unwell_list\" data-key=\"How severe is it?\" ><option value=''>How severe is it?<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_8\"  class='ff-t-container ff-column-container ff_columns_total_1 ff-hidden'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_gu_base' id='label_ff_3_gu_base' aria-label=\"gu_base\">gu_base<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"gu_base\" id=\"ff_3_gu_base\" class=\"ff-el-form-control\" data-name=\"gu_base\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_gu_onset' id='label_ff_3_gu_onset' aria-label=\"gu_onset\">gu_onset<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"gu_onset\" id=\"ff_3_gu_onset\" class=\"ff-el-form-control\" data-name=\"gu_onset\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_gu_percept' id='label_ff_3_gu_percept' aria-label=\"gu_percept\">gu_percept<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"gu_percept\" id=\"ff_3_gu_percept\" class=\"ff-el-form-control\" data-name=\"gu_percept\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_gu_context' id='label_ff_3_gu_context' aria-label=\"gu_context\">gu_context<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"gu_context\" id=\"ff_3_gu_context\" class=\"ff-el-form-control\" data-name=\"gu_context\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_gu_total' id='label_ff_3_gu_total' aria-label=\"gu_total\">gu_total<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"gu_total\" id=\"ff_3_gu_total\" class=\"ff-el-form-control\" data-name=\"gu_total\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_9\"  class='ff-t-container ff-column-container ff_columns_total_1 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Hearing feels blocked or muffled\">Hearing feels blocked or muffled<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='Blocked_muffled_a12826f15d4632e66d4adb65a9c8f54a'><input  type=\"checkbox\" name=\"Blocked_muffled[]\" data-name=\"Blocked_muffled\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"My hearing feels blocked or muffled\" data-calc_value=\"1\"  id='Blocked_muffled_a12826f15d4632e66d4adb65a9c8f54a' aria-label='My hearing feels blocked or muffled' aria-invalid='false' aria-required=false> <span>My hearing feels blocked or muffled<\/span><\/label><\/div><\/div><\/div><div class=\"has-conditions  ff-field_container ff-chained-select-field-wrapper\" data-type=\"chained-select\" data-name=\"blocked_muffled_list\" data-source-type=\"file\" ><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_blocked_muffled_list_Which_ear?_' id='label_ff_3_blocked_muffled_list_Which_ear?_' aria-label=\"Which ear?\">Which ear?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"blocked_muffled_list[Which ear?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"blocked_muffled_list\" data-source-type=\"file\" id=\"ff_3_blocked_muffled_list_Which_ear?_\" data-index=\"0\" data-meta_key=\"chained_select_blocked_muffled_list\" data-key=\"Which ear?\" ><option value=''>Which ear?<\/option><option value='Left ear'>Left ear<\/option><option value='Right ear'>Right ear<\/option><option value='Both ears'>Both ears<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_blocked_muffled_list_When_did_this_start?_' id='label_ff_3_blocked_muffled_list_When_did_this_start?_' aria-label=\"When did this start?\">When did this start?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"blocked_muffled_list[When did this start?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"blocked_muffled_list\" data-source-type=\"file\" id=\"ff_3_blocked_muffled_list_When_did_this_start?_\" data-index=\"1\" data-meta_key=\"chained_select_blocked_muffled_list\" data-key=\"When did this start?\" ><option value=''>When did this start?<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_blocked_muffled_list_What_does_it_feel_like?_' id='label_ff_3_blocked_muffled_list_What_does_it_feel_like?_' aria-label=\"What does it feel like?\">What does it feel like?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"blocked_muffled_list[What does it feel like?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"blocked_muffled_list\" data-source-type=\"file\" id=\"ff_3_blocked_muffled_list_What_does_it_feel_like?_\" data-index=\"2\" data-meta_key=\"chained_select_blocked_muffled_list\" data-key=\"What does it feel like?\" ><option value=''>What does it feel like?<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_10\"  class='ff-t-container ff-column-container ff_columns_total_1 ff-hidden'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_bm_base' id='label_ff_3_bm_base' aria-label=\"bm_base\">bm_base<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"bm_base\" id=\"ff_3_bm_base\" class=\"ff-el-form-control\" data-name=\"bm_base\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_bm_onset' id='label_ff_3_bm_onset' aria-label=\"bm_onset\">bm_onset<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"bm_onset\" id=\"ff_3_bm_onset\" class=\"ff-el-form-control\" data-name=\"bm_onset\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_bm_percept' id='label_ff_3_bm_percept' aria-label=\"bm_percept\">bm_percept<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"bm_percept\" id=\"ff_3_bm_percept\" class=\"ff-el-form-control\" data-name=\"bm_percept\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_bm_context' id='label_ff_3_bm_context' aria-label=\"bm_context\">bm_context<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"bm_context\" id=\"ff_3_bm_context\" class=\"ff-el-form-control\" data-name=\"bm_context\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_bm_total' id='label_ff_3_bm_total' aria-label=\"bm_total\">bm_total<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"bm_total\" id=\"ff_3_bm_total\" class=\"ff-el-form-control\" data-name=\"bm_total\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_11\"  class='ff-t-container ff-column-container ff_columns_total_1 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Ear-wax\">Ear-wax<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='Ear_wax_0b8bbb841d7daec6a325550bd904ecec'><input  type=\"checkbox\" name=\"Ear_wax[]\" data-name=\"Ear_wax\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"I think I might have ear-wax\" data-calc_value=\"1\"  id='Ear_wax_0b8bbb841d7daec6a325550bd904ecec' aria-label='I think I might have ear-wax' aria-invalid='false' aria-required=false> <span>I think I might have ear-wax<\/span><\/label><\/div><\/div><\/div><div class=\"has-conditions  ff-field_container ff-chained-select-field-wrapper\" data-type=\"chained-select\" data-name=\"ear_wax_list\" data-source-type=\"file\" ><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_ear_wax_list_Which_ear?_' id='label_ff_3_ear_wax_list_Which_ear?_' aria-label=\"Which ear?\">Which ear?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"ear_wax_list[Which ear?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"ear_wax_list\" data-source-type=\"file\" id=\"ff_3_ear_wax_list_Which_ear?_\" data-index=\"0\" data-meta_key=\"chained_select_ear_wax_list\" data-key=\"Which ear?\" ><option value=''>Which ear?<\/option><option value='Left ear'>Left ear<\/option><option value='Right ear'>Right ear<\/option><option value='Both ears'>Both ears<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_ear_wax_list_When_did_this_start?_' id='label_ff_3_ear_wax_list_When_did_this_start?_' aria-label=\"When did this start?\">When did this start?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"ear_wax_list[When did this start?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"ear_wax_list\" data-source-type=\"file\" id=\"ff_3_ear_wax_list_When_did_this_start?_\" data-index=\"1\" data-meta_key=\"chained_select_ear_wax_list\" data-key=\"When did this start?\" ><option value=''>When did this start?<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_ear_wax_list_Why_do_you_think_it_is_wax?_' id='label_ff_3_ear_wax_list_Why_do_you_think_it_is_wax?_' aria-label=\"Why do you think it is wax?\">Why do you think it is wax?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"ear_wax_list[Why do you think it is wax?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"ear_wax_list\" data-source-type=\"file\" id=\"ff_3_ear_wax_list_Why_do_you_think_it_is_wax?_\" data-index=\"2\" data-meta_key=\"chained_select_ear_wax_list\" data-key=\"Why do you think it is wax?\" ><option value=''>Why do you think it is wax?<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_12\"  class='ff-t-container ff-column-container ff_columns_total_1 ff-hidden'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_ew_base' id='label_ff_3_ew_base' aria-label=\"ew_base\">ew_base<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"ew_base\" id=\"ff_3_ew_base\" class=\"ff-el-form-control\" data-name=\"ew_base\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_ew_onset' id='label_ff_3_ew_onset' aria-label=\"ew_onset\">ew_onset<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"ew_onset\" id=\"ff_3_ew_onset\" class=\"ff-el-form-control\" data-name=\"ew_onset\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_ew_percept' id='label_ff_3_ew_percept' aria-label=\"ew_percept\">ew_percept<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"ew_percept\" id=\"ff_3_ew_percept\" class=\"ff-el-form-control\" data-name=\"ew_percept\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_ew_context' id='label_ff_3_ew_context' aria-label=\"ew_context\">ew_context<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"ew_context\" id=\"ff_3_ew_context\" class=\"ff-el-form-control\" data-name=\"ew_context\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_ew_total' id='label_ff_3_ew_total' aria-label=\"ew_total\">ew_total<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"ew_total\" id=\"ff_3_ew_total\" class=\"ff-el-form-control\" data-name=\"ew_total\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_13\"  class='ff-t-container ff-column-container ff_columns_total_1 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Ear feels full \/ under pressure\">Ear feels full \/ under pressure<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='Full_pressure_5d722cf4190ca0c4c97c4a49def88012'><input  type=\"checkbox\" name=\"Full_pressure[]\" data-name=\"Full_pressure\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"My ear feels full \/ under pressure\" data-calc_value=\"1\"  id='Full_pressure_5d722cf4190ca0c4c97c4a49def88012' aria-label='My ear feels full \/ under pressure' aria-invalid='false' aria-required=false> <span>My ear feels full \/ under pressure<\/span><\/label><\/div><\/div><\/div><div class=\"has-conditions  ff-field_container ff-chained-select-field-wrapper\" data-type=\"chained-select\" data-name=\"full_under_pressure_list\" data-source-type=\"file\" ><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_full_under_pressure_list_Which_ear?_' id='label_ff_3_full_under_pressure_list_Which_ear?_' aria-label=\"Which ear?\">Which ear?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"full_under_pressure_list[Which ear?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"full_under_pressure_list\" data-source-type=\"file\" id=\"ff_3_full_under_pressure_list_Which_ear?_\" data-index=\"0\" data-meta_key=\"chained_select_full_under_pressure_list\" data-key=\"Which ear?\" ><option value=''>Which ear?<\/option><option value='Left ear'>Left ear<\/option><option value='Right ear'>Right ear<\/option><option value='Both ears'>Both ears<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_full_under_pressure_list_When_did_this_start?_' id='label_ff_3_full_under_pressure_list_When_did_this_start?_' aria-label=\"When did this start?\">When did this start?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"full_under_pressure_list[When did this start?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"full_under_pressure_list\" data-source-type=\"file\" id=\"ff_3_full_under_pressure_list_When_did_this_start?_\" data-index=\"1\" data-meta_key=\"chained_select_full_under_pressure_list\" data-key=\"When did this start?\" ><option value=''>When did this start?<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_full_under_pressure_list_What_happened_before_it_started?_' id='label_ff_3_full_under_pressure_list_What_happened_before_it_started?_' aria-label=\"What happened before it started?\">What happened before it started?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"full_under_pressure_list[What happened before it started?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"full_under_pressure_list\" data-source-type=\"file\" id=\"ff_3_full_under_pressure_list_What_happened_before_it_started?_\" data-index=\"2\" data-meta_key=\"chained_select_full_under_pressure_list\" data-key=\"What happened before it started?\" ><option value=''>What happened before it started?<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_14\"  class='ff-t-container ff-column-container ff_columns_total_1 ff-hidden'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_fp_base' id='label_ff_3_fp_base' aria-label=\"fp_base\">fp_base<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"fp_base\" id=\"ff_3_fp_base\" class=\"ff-el-form-control\" data-name=\"fp_base\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_fp_onset' id='label_ff_3_fp_onset' aria-label=\"fp_onset\">fp_onset<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"fp_onset\" id=\"ff_3_fp_onset\" class=\"ff-el-form-control\" data-name=\"fp_onset\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_fp_percept' id='label_ff_3_fp_percept' aria-label=\"fp_percept\">fp_percept<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"fp_percept\" id=\"ff_3_fp_percept\" class=\"ff-el-form-control\" data-name=\"fp_percept\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_fp_context' id='label_ff_3_fp_context' aria-label=\"fp_context\">fp_context<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"fp_context\" id=\"ff_3_fp_context\" class=\"ff-el-form-control\" data-name=\"fp_context\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_fp_total' id='label_ff_3_fp_total' aria-label=\"fp_total\">fp_total<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"fp_total\" id=\"ff_3_fp_total\" class=\"ff-el-form-control\" data-name=\"fp_total\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_15\"  class='ff-t-container ff-column-container ff_columns_total_1 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Ear Pain\">Ear Pain<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='Ear_Pain_cc30104e35d2c0486b61aea1015f2e65'><input  type=\"checkbox\" name=\"Ear_Pain[]\" data-name=\"Ear_Pain\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"I have ear-pain\" data-calc_value=\"1\"  id='Ear_Pain_cc30104e35d2c0486b61aea1015f2e65' aria-label='I have ear-pain' aria-invalid='false' aria-required=false> <span>I have ear-pain<\/span><\/label><\/div><\/div><\/div><div class=\"has-conditions  ff-field_container ff-chained-select-field-wrapper\" data-type=\"chained-select\" data-name=\"ear_pain_list\" data-source-type=\"file\" ><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_ear_pain_list_Which_ear?_' id='label_ff_3_ear_pain_list_Which_ear?_' aria-label=\"Which ear?\">Which ear?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"ear_pain_list[Which ear?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"ear_pain_list\" data-source-type=\"file\" id=\"ff_3_ear_pain_list_Which_ear?_\" data-index=\"0\" data-meta_key=\"chained_select_ear_pain_list\" data-key=\"Which ear?\" ><option value=''>Which ear?<\/option><option value='Left ear'>Left ear<\/option><option value='Right ear'>Right ear<\/option><option value='Both ears'>Both ears<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_ear_pain_list_When_did_this_start?_' id='label_ff_3_ear_pain_list_When_did_this_start?_' aria-label=\"When did this start?\">When did this start?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"ear_pain_list[When did this start?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"ear_pain_list\" data-source-type=\"file\" id=\"ff_3_ear_pain_list_When_did_this_start?_\" data-index=\"1\" data-meta_key=\"chained_select_ear_pain_list\" data-key=\"When did this start?\" ><option value=''>When did this start?<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_ear_pain_list_What_does_it_feel_like?_' id='label_ff_3_ear_pain_list_What_does_it_feel_like?_' aria-label=\"What does it feel like?\">What does it feel like?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"ear_pain_list[What does it feel like?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"ear_pain_list\" data-source-type=\"file\" id=\"ff_3_ear_pain_list_What_does_it_feel_like?_\" data-index=\"2\" data-meta_key=\"chained_select_ear_pain_list\" data-key=\"What does it feel like?\" ><option value=''>What does it feel like?<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_16\"  class='ff-t-container ff-column-container ff_columns_total_1 ff-hidden'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_ep_base' id='label_ff_3_ep_base' aria-label=\"ep_base\">ep_base<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"ep_base\" id=\"ff_3_ep_base\" class=\"ff-el-form-control\" data-name=\"ep_base\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_ep_onset' id='label_ff_3_ep_onset' aria-label=\"ep_onset\">ep_onset<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"ep_onset\" id=\"ff_3_ep_onset\" class=\"ff-el-form-control\" data-name=\"ep_onset\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_ep_percept' id='label_ff_3_ep_percept' aria-label=\"ep_percept\">ep_percept<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"ep_percept\" id=\"ff_3_ep_percept\" class=\"ff-el-form-control\" data-name=\"ep_percept\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_ep_context' id='label_ff_3_ep_context' aria-label=\"ep_context\">ep_context<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"ep_context\" id=\"ff_3_ep_context\" class=\"ff-el-form-control\" data-name=\"ep_context\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_ep_total' id='label_ff_3_ep_total' aria-label=\"ep_total\">ep_total<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"ep_total\" id=\"ff_3_ep_total\" class=\"ff-el-form-control\" data-name=\"ep_total\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_17\"  class='ff-t-container ff-column-container ff_columns_total_1 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Fluid Discharge\">Fluid Discharge<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='Fluid_Discharge_d65efc49bd641956c8102a9a2e6056d3'><input  type=\"checkbox\" name=\"Fluid_Discharge[]\" data-name=\"Fluid_Discharge\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"I have fluid or discharge from my ear\" data-calc_value=\"1\"  id='Fluid_Discharge_d65efc49bd641956c8102a9a2e6056d3' aria-label='I have fluid or discharge from my ear' aria-invalid='false' aria-required=false> <span>I have fluid or discharge from my ear<\/span><\/label><\/div><\/div><\/div><div class=\"has-conditions  ff-field_container ff-chained-select-field-wrapper\" data-type=\"chained-select\" data-name=\"fluid_discharge_list\" data-source-type=\"file\" ><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_fluid_discharge_list_Which_ear?_' id='label_ff_3_fluid_discharge_list_Which_ear?_' aria-label=\"Which ear?\">Which ear?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"fluid_discharge_list[Which ear?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"fluid_discharge_list\" data-source-type=\"file\" id=\"ff_3_fluid_discharge_list_Which_ear?_\" data-index=\"0\" data-meta_key=\"chained_select_fluid_discharge_list\" data-key=\"Which ear?\" ><option value=''>Which ear?<\/option><option value='Left ear'>Left ear<\/option><option value='Right ear'>Right ear<\/option><option value='Both ears'>Both ears<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_fluid_discharge_list_When_did_this_start?_' id='label_ff_3_fluid_discharge_list_When_did_this_start?_' aria-label=\"When did this start?\">When did this start?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"fluid_discharge_list[When did this start?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"fluid_discharge_list\" data-source-type=\"file\" id=\"ff_3_fluid_discharge_list_When_did_this_start?_\" data-index=\"1\" data-meta_key=\"chained_select_fluid_discharge_list\" data-key=\"When did this start?\" ><option value=''>When did this start?<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_fluid_discharge_list_What_does_it_look_or_feel_like?_' id='label_ff_3_fluid_discharge_list_What_does_it_look_or_feel_like?_' aria-label=\"What does it look or feel like?\">What does it look or feel like?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"fluid_discharge_list[What does it look or feel like?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"fluid_discharge_list\" data-source-type=\"file\" id=\"ff_3_fluid_discharge_list_What_does_it_look_or_feel_like?_\" data-index=\"2\" data-meta_key=\"chained_select_fluid_discharge_list\" data-key=\"What does it look or feel like?\" ><option value=''>What does it look or feel like?<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_18\"  class='ff-t-container ff-column-container ff_columns_total_1 ff-hidden'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_fd_base' id='label_ff_3_fd_base' aria-label=\"fd_base\">fd_base<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"fd_base\" id=\"ff_3_fd_base\" class=\"ff-el-form-control\" data-name=\"fd_base\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_fd_onset' id='label_ff_3_fd_onset' aria-label=\"fd_onset\">fd_onset<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"fd_onset\" id=\"ff_3_fd_onset\" class=\"ff-el-form-control\" data-name=\"fd_onset\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_fd_percept' id='label_ff_3_fd_percept' aria-label=\"fd_percept\">fd_percept<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"fd_percept\" id=\"ff_3_fd_percept\" class=\"ff-el-form-control\" data-name=\"fd_percept\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_fd_context' id='label_ff_3_fd_context' aria-label=\"fd_context\">fd_context<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"fd_context\" id=\"ff_3_fd_context\" class=\"ff-el-form-control\" data-name=\"fd_context\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_fd_total' id='label_ff_3_fd_total' aria-label=\"fd_total\">fd_total<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"fd_total\" id=\"ff_3_fd_total\" class=\"ff-el-form-control\" data-name=\"fd_total\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_19\"  class='ff-t-container ff-column-container ff_columns_total_1 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Gradual Change\">Gradual Change<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='Gradual_Change_44292b31496d2ce95889333e97bd1292'><input  type=\"checkbox\" name=\"Gradual_Change[]\" data-name=\"Gradual_Change\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"I\u2019ve had a gradual change in my hearing\" data-calc_value=\"1\"  id='Gradual_Change_44292b31496d2ce95889333e97bd1292' aria-label='I\u2019ve had a gradual change in my hearing' aria-invalid='false' aria-required=false> <span>I\u2019ve had a gradual change in my hearing<\/span><\/label><\/div><\/div><\/div><div class=\"has-conditions  ff-field_container ff-chained-select-field-wrapper\" data-type=\"chained-select\" data-name=\"gradual_change_list\" data-source-type=\"file\" ><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_gradual_change_list_Which_ear?_' id='label_ff_3_gradual_change_list_Which_ear?_' aria-label=\"Which ear?\">Which ear?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"gradual_change_list[Which ear?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"gradual_change_list\" data-source-type=\"file\" id=\"ff_3_gradual_change_list_Which_ear?_\" data-index=\"0\" data-meta_key=\"chained_select_gradual_change_list\" data-key=\"Which ear?\" ><option value=''>Which ear?<\/option><option value='Both ears'>Both ears<\/option><option value='Left ear'>Left ear<\/option><option value='Right ear'>Right ear<\/option><option value='Not sure'>Not sure<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_gradual_change_list_How_long_has_this_been_a_concern?_' id='label_ff_3_gradual_change_list_How_long_has_this_been_a_concern?_' aria-label=\"How long has this been a concern?\">How long has this been a concern?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"gradual_change_list[How long has this been a concern?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"gradual_change_list\" data-source-type=\"file\" id=\"ff_3_gradual_change_list_How_long_has_this_been_a_concern?_\" data-index=\"1\" data-meta_key=\"chained_select_gradual_change_list\" data-key=\"How long has this been a concern?\" ><option value=''>How long has this been a concern?<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_gradual_change_list_What_is_the_main_difficulty?_' id='label_ff_3_gradual_change_list_What_is_the_main_difficulty?_' aria-label=\"What is the main difficulty?\">What is the main difficulty?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"gradual_change_list[What is the main difficulty?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"gradual_change_list\" data-source-type=\"file\" id=\"ff_3_gradual_change_list_What_is_the_main_difficulty?_\" data-index=\"2\" data-meta_key=\"chained_select_gradual_change_list\" data-key=\"What is the main difficulty?\" ><option value=''>What is the main difficulty?<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_20\"  class='ff-t-container ff-column-container ff_columns_total_1 ff-hidden'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_gc_base' id='label_ff_3_gc_base' aria-label=\"gc_base\">gc_base<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"gc_base\" id=\"ff_3_gc_base\" class=\"ff-el-form-control\" data-name=\"gc_base\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_gc_onset' id='label_ff_3_gc_onset' aria-label=\"gc_onset\">gc_onset<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"gc_onset\" id=\"ff_3_gc_onset\" class=\"ff-el-form-control\" data-name=\"gc_onset\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_gc_percept' id='label_ff_3_gc_percept' aria-label=\"gc_percept\">gc_percept<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"gc_percept\" id=\"ff_3_gc_percept\" class=\"ff-el-form-control\" data-name=\"gc_percept\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_gc_context' id='label_ff_3_gc_context' aria-label=\"gc_context\">gc_context<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"gc_context\" id=\"ff_3_gc_context\" class=\"ff-el-form-control\" data-name=\"gc_context\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_gc_total' id='label_ff_3_gc_total' aria-label=\"gc_total\">gc_total<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"gc_total\" id=\"ff_3_gc_total\" class=\"ff-el-form-control\" data-name=\"gc_total\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_21\"  class='ff-t-container ff-column-container ff_columns_total_1 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Hearing Aid Issues\">Hearing Aid Issues<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='Hearing_Aid_Issues_8fb60546fb84379b218b5f900270179b'><input  type=\"checkbox\" name=\"Hearing_Aid_Issues[]\" data-name=\"Hearing_Aid_Issues\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\" I\u2019m having issues with my hearing aids\" data-calc_value=\"1\"  id='Hearing_Aid_Issues_8fb60546fb84379b218b5f900270179b' aria-label='I\u2019m having issues with my hearing aids' aria-invalid='false' aria-required=false> <span> I\u2019m having issues with my hearing aids<\/span><\/label><\/div><\/div><\/div><div class=\"has-conditions  ff-field_container ff-chained-select-field-wrapper\" data-type=\"chained-select\" data-name=\"hearing_aid_list\" data-source-type=\"file\" ><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_hearing_aid_list_Which_ear?_' id='label_ff_3_hearing_aid_list_Which_ear?_' aria-label=\"Which ear?\">Which ear?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"hearing_aid_list[Which ear?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"hearing_aid_list\" data-source-type=\"file\" id=\"ff_3_hearing_aid_list_Which_ear?_\" data-index=\"0\" data-meta_key=\"chained_select_hearing_aid_list\" data-key=\"Which ear?\" ><option value=''>Which ear?<\/option><option value='Left ear'>Left ear<\/option><option value='Right ear'>Right ear<\/option><option value='Both ears'>Both ears<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_hearing_aid_list_What_is_the_main_issue?_' id='label_ff_3_hearing_aid_list_What_is_the_main_issue?_' aria-label=\"What is the main issue?\">What is the main issue?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"hearing_aid_list[What is the main issue?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"hearing_aid_list\" data-source-type=\"file\" id=\"ff_3_hearing_aid_list_What_is_the_main_issue?_\" data-index=\"1\" data-meta_key=\"chained_select_hearing_aid_list\" data-key=\"What is the main issue?\" ><option value=''>What is the main issue?<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_hearing_aid_list_How_old_is_the_device?_' id='label_ff_3_hearing_aid_list_How_old_is_the_device?_' aria-label=\"How old is the device?\">How old is the device?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"hearing_aid_list[How old is the device?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"hearing_aid_list\" data-source-type=\"file\" id=\"ff_3_hearing_aid_list_How_old_is_the_device?_\" data-index=\"2\" data-meta_key=\"chained_select_hearing_aid_list\" data-key=\"How old is the device?\" ><option value=''>How old is the device?<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_22\"  class='ff-t-container ff-column-container ff_columns_total_1 ff-hidden'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_ha_base' id='label_ff_3_ha_base' aria-label=\"ha_base\">ha_base<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"ha_base\" id=\"ff_3_ha_base\" class=\"ff-el-form-control\" data-name=\"ha_base\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_ha_onset' id='label_ff_3_ha_onset' aria-label=\"ha_onset\">ha_onset<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"ha_onset\" id=\"ff_3_ha_onset\" class=\"ff-el-form-control\" data-name=\"ha_onset\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_ha_percept' id='label_ff_3_ha_percept' aria-label=\"ha_percept\">ha_percept<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"ha_percept\" id=\"ff_3_ha_percept\" class=\"ff-el-form-control\" data-name=\"ha_percept\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_ha_context' id='label_ff_3_ha_context' aria-label=\"ha_context\">ha_context<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"ha_context\" id=\"ff_3_ha_context\" class=\"ff-el-form-control\" data-name=\"ha_context\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_ha_total' id='label_ff_3_ha_total' aria-label=\"ha_total\">ha_total<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"ha_total\" id=\"ff_3_ha_total\" class=\"ff-el-form-control\" data-name=\"ha_total\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_23\"  class='ff-t-container ff-column-container ff_columns_total_1 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Off\u2011balance or Dizzy\">Off\u2011balance or Dizzy<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='Dizzy_b7f92bd8fbdf8658460f86ba62378c06'><input  type=\"checkbox\" name=\"Dizzy[]\" data-name=\"Dizzy\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"I feel off\u2011balance or dizzy\" data-calc_value=\"1\"  id='Dizzy_b7f92bd8fbdf8658460f86ba62378c06' aria-label='I feel off\u2011balance or dizzy' aria-invalid='false' aria-required=false> <span>I feel off\u2011balance or dizzy<\/span><\/label><\/div><\/div><\/div><div class=\"has-conditions  ff-field_container ff-chained-select-field-wrapper\" data-type=\"chained-select\" data-name=\"dizzy_list\" data-source-type=\"file\" ><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dizzy_list_Which_ear_(if_known)?_' id='label_ff_3_dizzy_list_Which_ear_(if_known)?_' aria-label=\"Which ear (if known)?\">Which ear (if known)?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"dizzy_list[Which ear (if known)?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"dizzy_list\" data-source-type=\"file\" id=\"ff_3_dizzy_list_Which_ear_(if_known)?_\" data-index=\"0\" data-meta_key=\"chained_select_dizzy_list\" data-key=\"Which ear (if known)?\" ><option value=''>Which ear (if known)?<\/option><option value='Left ear'>Left ear<\/option><option value='Right ear'>Right ear<\/option><option value='Not sure\/Both'>Not sure\/Both<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dizzy_list_When_did_this_start?_' id='label_ff_3_dizzy_list_When_did_this_start?_' aria-label=\"When did this start?\">When did this start?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"dizzy_list[When did this start?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"dizzy_list\" data-source-type=\"file\" id=\"ff_3_dizzy_list_When_did_this_start?_\" data-index=\"1\" data-meta_key=\"chained_select_dizzy_list\" data-key=\"When did this start?\" ><option value=''>When did this start?<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dizzy_list_What_does_it_feel_like?_' id='label_ff_3_dizzy_list_What_does_it_feel_like?_' aria-label=\"What does it feel like?\">What does it feel like?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"dizzy_list[What does it feel like?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"dizzy_list\" data-source-type=\"file\" id=\"ff_3_dizzy_list_What_does_it_feel_like?_\" data-index=\"2\" data-meta_key=\"chained_select_dizzy_list\" data-key=\"What does it feel like?\" ><option value=''>What does it feel like?<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_24\"  class='ff-t-container ff-column-container ff_columns_total_1 ff-hidden'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dz_base' id='label_ff_3_dz_base' aria-label=\"dz_base\">dz_base<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"dz_base\" id=\"ff_3_dz_base\" class=\"ff-el-form-control\" data-name=\"dz_base\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dz_onset' id='label_ff_3_dz_onset' aria-label=\"dz_onset\">dz_onset<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"dz_onset\" id=\"ff_3_dz_onset\" class=\"ff-el-form-control\" data-name=\"dz_onset\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dz_percept' id='label_ff_3_dz_percept' aria-label=\"dz_percept\">dz_percept<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"dz_percept\" id=\"ff_3_dz_percept\" class=\"ff-el-form-control\" data-name=\"dz_percept\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dz_context' id='label_ff_3_dz_context' aria-label=\"dz_context\">dz_context<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"dz_context\" id=\"ff_3_dz_context\" class=\"ff-el-form-control\" data-name=\"dz_context\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dz_total' id='label_ff_3_dz_total' aria-label=\"dz_total\">dz_total<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"dz_total\" id=\"ff_3_dz_total\" class=\"ff-el-form-control\" data-name=\"dz_total\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_25\"  class='ff-t-container ff-column-container ff_columns_total_1 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Not sure\">Not sure<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='Not_sure_ca16d9b97fd1bcfe0e80a12c6e442115'><input  type=\"checkbox\" name=\"Not_sure[]\" data-name=\"Not_sure\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"I&#039;m not sure\" data-calc_value=\"1\"  id='Not_sure_ca16d9b97fd1bcfe0e80a12c6e442115' aria-label='I&#039;m not sure' aria-invalid='false' aria-required=false> <span>I'm not sure<\/span><\/label><\/div><\/div><\/div><div class=\"has-conditions  ff-field_container ff-chained-select-field-wrapper\" data-type=\"chained-select\" data-name=\"not_sure_list\" data-source-type=\"file\" ><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_not_sure_list_What_are_you_unsure_about?_' id='label_ff_3_not_sure_list_What_are_you_unsure_about?_' aria-label=\"What are you unsure about?\">What are you unsure about?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"not_sure_list[What are you unsure about?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"not_sure_list\" data-source-type=\"file\" id=\"ff_3_not_sure_list_What_are_you_unsure_about?_\" data-index=\"0\" data-meta_key=\"chained_select_not_sure_list\" data-key=\"What are you unsure about?\" ><option value=''>What are you unsure about?<\/option><option value='General ear discomfort'>General ear discomfort<\/option><option value='General hearing difficulty'>General hearing difficulty<\/option><option value='General balance issues'>General balance issues<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_not_sure_list_When_did_this_start?_' id='label_ff_3_not_sure_list_When_did_this_start?_' aria-label=\"When did this start?\">When did this start?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"not_sure_list[When did this start?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"not_sure_list\" data-source-type=\"file\" id=\"ff_3_not_sure_list_When_did_this_start?_\" data-index=\"1\" data-meta_key=\"chained_select_not_sure_list\" data-key=\"When did this start?\" ><option value=''>When did this start?<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_not_sure_list_What_does_it_feel_like?_' id='label_ff_3_not_sure_list_What_does_it_feel_like?_' aria-label=\"What does it feel like?\">What does it feel like?<\/label><\/div><div class='ff-el-input--content'><select disabled name=\"not_sure_list[What does it feel like?]\" class=\"ff-el-form-control  el-chained-select\" data-name=\"not_sure_list\" data-source-type=\"file\" id=\"ff_3_not_sure_list_What_does_it_feel_like?_\" data-index=\"2\" data-meta_key=\"chained_select_not_sure_list\" data-key=\"What does it feel like?\" ><option value=''>What does it feel like?<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_26\"  class='ff-t-container ff-column-container ff_columns_total_1 ff-hidden'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_ns_base' id='label_ff_3_ns_base' aria-label=\"ns_base\">ns_base<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"ns_base\" id=\"ff_3_ns_base\" class=\"ff-el-form-control\" data-name=\"ns_base\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_ns_onset' id='label_ff_3_ns_onset' aria-label=\"ns_onset\">ns_onset<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"ns_onset\" id=\"ff_3_ns_onset\" class=\"ff-el-form-control\" data-name=\"ns_onset\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_ns_percept' id='label_ff_3_ns_percept' aria-label=\"ns_percept\">ns_percept<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"ns_percept\" id=\"ff_3_ns_percept\" class=\"ff-el-form-control\" data-name=\"ns_percept\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_ns_context' id='label_ff_3_ns_context' aria-label=\"ns_context\">ns_context<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"ns_context\" id=\"ff_3_ns_context\" class=\"ff-el-form-control\" data-name=\"ns_context\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_ns_total' id='label_ff_3_ns_total' aria-label=\"ns_total\">ns_total<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"ns_total\" id=\"ff_3_ns_total\" class=\"ff-el-form-control\" data-name=\"ns_total\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group ff-hidden'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_rf_total' id='label_ff_3_rf_total' aria-label=\"rf_total\">rf_total<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"rf_total\" id=\"ff_3_rf_total\" class=\"ff-el-form-control\" data-name=\"rf_total\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Goal\">Goal<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='motivation_57c7727327115bd33dc171cb1ffe31d0'><input  type=\"radio\" name=\"motivation\" data-name=\"motivation\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Seeking professional guidance\" data-calc_value=\"3\"  id='motivation_57c7727327115bd33dc171cb1ffe31d0' aria-label='Seeking professional guidance' aria-invalid='false' aria-required=true> <span>Seeking professional guidance<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='motivation_6260c8692c5f2b4990e7e89e1bbfc596'><input  type=\"radio\" name=\"motivation\" data-name=\"motivation\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"I want to improve my hearing in daily life\" data-calc_value=\"2\"  id='motivation_6260c8692c5f2b4990e7e89e1bbfc596' aria-label='I want to improve my hearing in daily life' aria-invalid='false' aria-required=true> <span>I want to improve my hearing in daily life<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='motivation_696865b765a3afdae8dafb3ca1afe419'><input  type=\"radio\" name=\"motivation\" data-name=\"motivation\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"I want to keep up with conversations\" data-calc_value=\"2\"  id='motivation_696865b765a3afdae8dafb3ca1afe419' aria-label='I want to keep up with conversations' aria-invalid='false' aria-required=true> <span>I want to keep up with conversations<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='motivation_67084fdb53892e94cd1ca41519bc88fa'><input  type=\"radio\" name=\"motivation\" data-name=\"motivation\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"I want reassurance \/ a check\u2011up\" data-calc_value=\"1\"  id='motivation_67084fdb53892e94cd1ca41519bc88fa' aria-label='I want reassurance \/ a check\u2011up' aria-invalid='false' aria-required=true> <span>I want reassurance \/ a check\u2011up<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='motivation_4426722ee85b23bf37f2dd0d712d078e'><input  type=\"radio\" name=\"motivation\" data-name=\"motivation\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"I\u2019m exploring options \/ curious\" data-calc_value=\"0\"  id='motivation_4426722ee85b23bf37f2dd0d712d078e' aria-label='I\u2019m exploring options \/ curious' aria-invalid='false' aria-required=true> <span>I\u2019m exploring options \/ curious<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_3\" ><div class=\"ff-section-divider\"><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_4\" ><h3 style=\"text-align: center\">Medical and Hearing History<\/h3>\n<p style=\"text-align: center\"><em>Important context for your audiologist<\/em><\/p><\/div><div data-name=\"ff_cn_id_27\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Have you had a hearing test before?\">Have you had a hearing test before?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_ddb4fc3c173dba728c924f0090c8adf9'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_2_ddb4fc3c173dba728c924f0090c8adf9' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_8f4c2f25999f83bbddfdeb3562905465'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_2_8f4c2f25999f83bbddfdeb3562905465' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dropdown_1' id='label_ff_3_dropdown_1' aria-label=\"When was your last hearing test\">When was your last hearing test<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_1\" id=\"ff_3_dropdown_1\" class=\"ff-el-form-control\" data-name=\"dropdown_1\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"false\" aria-labelledby=\"label_ff_3_dropdown_1\"><option value=\"\">- Select -<\/option><option value=\"Within the last 6 months\"  >Within the last 6 months<\/option><option value=\"6\u201312 months ago\"  >6\u201312 months ago<\/option><option value=\"1\u20133 years ago\"  >1\u20133 years ago<\/option><option value=\"More than 3 years ago\"  >More than 3 years ago<\/option><\/select><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_28\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Do you currently use hearing aids?\">Do you currently use hearing aids?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_3_3e4a913bd51e814c9a0052b89c4643b6'><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_3_3e4a913bd51e814c9a0052b89c4643b6' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_3_81096b5bdbe5e7517bf6c09b8bd2385b'><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_3_81096b5bdbe5e7517bf6c09b8bd2385b' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Which ear(s) do you use hearing aids in?\">Which ear(s) do you use hearing aids in?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_e235552b3a50b5514a4bae448bb82656'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Left\"  id='checkbox_e235552b3a50b5514a4bae448bb82656' aria-label='Left' aria-invalid='false' aria-required=false> <span>Left<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_8a860ceb2299f52a074aca4d55936993'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Right\"  id='checkbox_8a860ceb2299f52a074aca4d55936993' aria-label='Right' aria-invalid='false' aria-required=false> <span>Right<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_e5a528c923b92a65c485bf46dba57be0'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Both\"  id='checkbox_e5a528c923b92a65c485bf46dba57be0' aria-label='Both' aria-invalid='false' aria-required=false> <span>Both<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_5\" ><div class=\"ff-section-divider\"><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_description_7' id='label_ff_3_description_7' aria-label=\"Do you have any other medical conditions we should be aware of?\">Do you have any other medical conditions we should be aware of?<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_3_description_7\" name=\"description_7\" id=\"ff_3_description_7\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"description_7\" ><\/textarea><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_6\" ><div class=\"ff-section-divider\"><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_7\" ><h3 style=\"text-align: center\">Appointment preferences<\/h3>\n<p style=\"text-align: center\"><em>When and how you\u2019d prefer to be seen<\/em><\/p><\/div><div data-name=\"ff_cn_id_29\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Preferred clinic location\">Preferred clinic location<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_27842790d74e79ff248190abee8b113a'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Alton\"  id='checkbox_1_27842790d74e79ff248190abee8b113a' aria-label='Alton' aria-invalid='false' aria-required=true> <span>Alton<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_8ccb524fe01dc38cd5ecb9a69374b12e'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Andover\"  id='checkbox_1_8ccb524fe01dc38cd5ecb9a69374b12e' aria-label='Andover' aria-invalid='false' aria-required=true> <span>Andover<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_5d037c9fc41d51bce61e90cf0f8c4373'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Basingstoke\"  id='checkbox_1_5d037c9fc41d51bce61e90cf0f8c4373' aria-label='Basingstoke' aria-invalid='false' aria-required=true> <span>Basingstoke<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_a17ad1841ec160dd0c065908a5385b90'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Eastleigh\"  id='checkbox_1_a17ad1841ec160dd0c065908a5385b90' aria-label='Eastleigh' aria-invalid='false' aria-required=true> <span>Eastleigh<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_ae93309027bace76afdf541c414a3d78'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Southampton\"  id='checkbox_1_ae93309027bace76afdf541c414a3d78' aria-label='Southampton' aria-invalid='false' aria-required=true> <span>Southampton<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_e307966125c106255c4197f2643974cd'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Winchester\"  id='checkbox_1_e307966125c106255c4197f2643974cd' aria-label='Winchester' aria-invalid='false' aria-required=true> <span>Winchester<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_0fcb0679e5f24d60e95f77b1dcc774b3'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Any location\"  id='checkbox_1_0fcb0679e5f24d60e95f77b1dcc774b3' aria-label='Any location' aria-invalid='false' aria-required=true> <span>Any location<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Which days work best for you?\">Which days work best for you?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_1d0f2e8c36986e1542a55b23d8941f0e'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Monday\"  id='checkbox_2_1d0f2e8c36986e1542a55b23d8941f0e' aria-label='Monday' aria-invalid='false' aria-required=true> <span>Monday<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_2fecfef96d5a516a56ef030b12621b4a'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Tuesday\"  id='checkbox_2_2fecfef96d5a516a56ef030b12621b4a' aria-label='Tuesday' aria-invalid='false' aria-required=true> <span>Tuesday<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_8f2e6be8f33195ab51884b9727353fe4'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Wednesday\"  id='checkbox_2_8f2e6be8f33195ab51884b9727353fe4' aria-label='Wednesday' aria-invalid='false' aria-required=true> <span>Wednesday<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_39beb1c078b1ea80d60d6fa4c4d03972'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Thursday\"  id='checkbox_2_39beb1c078b1ea80d60d6fa4c4d03972' aria-label='Thursday' aria-invalid='false' aria-required=true> <span>Thursday<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_5baf3c8f6ce5f32f03e334ed561ab3b0'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Friday\"  id='checkbox_2_5baf3c8f6ce5f32f03e334ed561ab3b0' aria-label='Friday' aria-invalid='false' aria-required=true> <span>Friday<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_5dcdade12232d5b98f2cc5a5db3df51f'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Saturday \"  id='checkbox_2_5dcdade12232d5b98f2cc5a5db3df51f' aria-label='Saturday' aria-invalid='false' aria-required=true> <span>Saturday <\/span><\/label><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_30\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Preferred time of day\">Preferred time of day<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_11_20494b2a4199d586c840b556b78b71d8'><input  type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Morning\"  id='input_radio_11_20494b2a4199d586c840b556b78b71d8' aria-label='Morning' aria-invalid='false' aria-required=true> <span>Morning<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_11_4a95dbd407d996d36ccdab992ad5de42'><input  type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Afternoon\"  id='input_radio_11_4a95dbd407d996d36ccdab992ad5de42' aria-label='Afternoon' aria-invalid='false' aria-required=true> <span>Afternoon<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_11_377b93e13a71adf3371c9fe055d2353f'><input  type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Either\"  id='input_radio_11_377b93e13a71adf3371c9fe055d2353f' aria-label='Either' aria-invalid='false' aria-required=true> <span>Either<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_description_8' id='label_ff_3_description_8' aria-label=\"Do you have any accessibility or communication needs?\">Do you have any accessibility or communication needs?<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_3_description_8\" name=\"description_8\" id=\"ff_3_description_8\" class=\"ff-el-form-control\" placeholder=\"e.g. wheelchair access, quiet waiting area, communication preferences\u2026\" rows=\"3\" cols=\"2\" data-name=\"description_8\" ><\/textarea><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_description_9' id='label_ff_3_description_9' aria-label=\"Anything else you\u2019d like us to know before your appointment?\">Anything else you\u2019d like us to know before your appointment?<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_3_description_9\" name=\"description_9\" id=\"ff_3_description_9\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"description_9\" ><\/textarea><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_8\" ><div class=\"ff-section-divider\"><\/div><\/div><div class='ff-el-group ff-hidden'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_final_bucket' id='label_ff_3_final_bucket' aria-label=\"final_bucket\">final_bucket<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"final_bucket\" id=\"ff_3_final_bucket\" class=\"ff-el-form-control\" data-name=\"final_bucket\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_9\" ><div id=\"clinical-summary-wrapper\" style=\"margin-top: 30px;border-radius: 8px;overflow: hidden;border: 1px solid #d1d9e0\">\n    \n    <!-- Report Header -->\n    <div style=\"background: #f1f4f7;padding: 14px 20px;border-bottom: 1px solid #d1d9e0;justify-content: space-between;align-items: center\">\n        <span style=\"font-weight: bold;color: #444;font-size: 13px;text-transform: uppercase;letter-spacing: 0.8px\">\n            Initial Triage Assessment Report\n        <\/span>\n        <span id=\"triage-timestamp\" style=\"font-size: 11px;color: #7f8c8d;font-weight: 500\">\n            <!-- JS will inject date here -->\n        <\/span>\n    <\/div>\n\n    <!-- Main Content Area -->\n    <div id=\"clinical-summary-content\" style=\"padding: 25px;background: #ffffff\">\n        <!-- JS injects content here -->\n    <\/div>\n\n    <!-- Footer -->\n    <div style=\"background: #fafbfc;padding: 15px 25px;border-top: 1px solid #eee\">\n        <p style=\"font-size: 12px;line-height: 1.5;color: #7f8c8d;margin: 0\">\n            <strong>Clinical Note:<\/strong> This summary is generated based on your reported symptoms for the purpose of clinical prioritisation. It provides a preliminary assessment only and does not constitute a formal diagnosis. \n        <\/p>\n    <\/div>\n<\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_10\" ><h3 style=\"text-align: center\">Consent and submission<\/h3>\n<p style=\"text-align: center\"><em>Your agreement and final checks<\/em><\/p><\/div><div class='ff-el-group'><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_3_4521467e4b67106d97a6a966f6ee5e25'><input  type=\"checkbox\" name=\"checkbox_3[]\" data-name=\"checkbox_3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"I confirm that the information provided is accurate to the best of my knowledge and I consent to this clinic contacting me regarding my enquiry.\"  id='checkbox_3_4521467e4b67106d97a6a966f6ee5e25' aria-label='I confirm that the information provided is accurate to the best of my knowledge and I consent to this clinic contacting me regarding my enquiry.' aria-invalid='false' aria-required=true> <span>I confirm that the information provided is accurate to the best of my knowledge and I consent to this clinic contacting me regarding my enquiry.<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_11\" ><p style=\"text-align: left\"><em>Your information will be handled confidentially and in accordance with our privacy policy<\/em>.<\/p><\/div><div class='ff-el-group  ff_list_inline'><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_4_330bda787742e5c5827c4248eb386583'><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"I would like to receive occasional updates, offers, or hearing\u2011health information.\"  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required\",\"global\":true},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\",\"global_message\":\"This field must contain numeric value\",\"global\":true},\"min\":{\"value\":\"\",\"message\":\"Validation fails for minimum value\",\"global_message\":\"Validation fails for minimum value\",\"global\":true},\"max\":{\"value\":\"\",\"message\":\"Validation fails for maximum value\",\"global_message\":\"Validation fails for maximum value\",\"global\":true},\"digits\":{\"value\":\"\",\"message\":\"Validation fails for limited digits\",\"global_message\":\"Validation fails for limited digits\",\"global\":true}},\"ew_total\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\",\"global_message\":\"This field must contain numeric value\",\"global\":true},\"min\":{\"value\":\"\",\"message\":\"Validation 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started?]\":{\"required\":{\"value\":true,\"global\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\"}},\"fp_base\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\",\"global_message\":\"This field must contain numeric value\",\"global\":true},\"min\":{\"value\":\"\",\"message\":\"Validation fails for minimum value\",\"global_message\":\"Validation fails for minimum value\",\"global\":true},\"max\":{\"value\":\"\",\"message\":\"Validation fails for maximum value\",\"global_message\":\"Validation fails for maximum value\",\"global\":true},\"digits\":{\"value\":\"\",\"message\":\"Validation fails for limited digits\",\"global_message\":\"Validation fails for limited digits\",\"global\":true}},\"fp_onset\":{\"required\":{\"value\":false,\"message\":\"This field is 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digits\",\"global\":true}},\"Ear_Pain\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"ear_pain_list[Which ear?]\":{\"required\":{\"value\":true,\"global\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\"}},\"ear_pain_list[When did this start?]\":{\"required\":{\"value\":true,\"global\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\"}},\"ear_pain_list[What does it feel like?]\":{\"required\":{\"value\":true,\"global\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\"}},\"ep_base\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\",\"global_message\":\"This field must contain numeric 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digits\",\"global\":true}},\"ep_context\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\",\"global_message\":\"This field must contain numeric value\",\"global\":true},\"min\":{\"value\":\"\",\"message\":\"Validation fails for minimum value\",\"global_message\":\"Validation fails for minimum value\",\"global\":true},\"max\":{\"value\":\"\",\"message\":\"Validation fails for maximum value\",\"global_message\":\"Validation fails for maximum value\",\"global\":true},\"digits\":{\"value\":\"\",\"message\":\"Validation fails for limited digits\",\"global_message\":\"Validation fails for limited digits\",\"global\":true}},\"ep_total\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"numeric\":{\"value\":true,\"message\":\"This field must 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is required\",\"global_message\":\"This field is required\"}},\"fluid_discharge_list[What does it look or feel like?]\":{\"required\":{\"value\":true,\"global\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\"}},\"fd_base\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\",\"global_message\":\"This field must contain numeric value\",\"global\":true},\"min\":{\"value\":\"\",\"message\":\"Validation fails for minimum value\",\"global_message\":\"Validation fails for minimum value\",\"global\":true},\"max\":{\"value\":\"\",\"message\":\"Validation fails for maximum value\",\"global_message\":\"Validation fails for maximum value\",\"global\":true},\"digits\":{\"value\":\"\",\"message\":\"Validation fails for limited digits\",\"global_message\":\"Validation fails for limited digits\",\"global\":true}},\"fd_onset\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\",\"global_message\":\"This field must contain numeric value\",\"global\":true},\"min\":{\"value\":\"\",\"message\":\"Validation fails for minimum value\",\"global_message\":\"Validation fails for minimum value\",\"global\":true},\"max\":{\"value\":\"\",\"message\":\"Validation fails for maximum value\",\"global_message\":\"Validation fails for maximum value\",\"global\":true},\"digits\":{\"value\":\"\",\"message\":\"Validation fails for limited digits\",\"global_message\":\"Validation fails for limited digits\",\"global\":true}},\"fd_percept\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"numeric\":{\"value\":true,\"message\":\"This field must 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value\",\"global\":true},\"max\":{\"value\":\"\",\"message\":\"Validation fails for maximum value\",\"global_message\":\"Validation fails for maximum value\",\"global\":true},\"digits\":{\"value\":\"\",\"message\":\"Validation fails for limited digits\",\"global_message\":\"Validation fails for limited digits\",\"global\":true}},\"fd_total\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\",\"global_message\":\"This field must contain numeric value\",\"global\":true},\"min\":{\"value\":\"\",\"message\":\"Validation fails for minimum value\",\"global_message\":\"Validation fails for minimum value\",\"global\":true},\"max\":{\"value\":\"\",\"message\":\"Validation fails for maximum value\",\"global_message\":\"Validation fails for maximum value\",\"global\":true},\"digits\":{\"value\":\"\",\"message\":\"Validation fails for 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contain numeric value\",\"global_message\":\"This field must contain numeric value\",\"global\":true},\"min\":{\"value\":\"\",\"message\":\"Validation fails for minimum value\",\"global_message\":\"Validation fails for minimum value\",\"global\":true},\"max\":{\"value\":\"\",\"message\":\"Validation fails for maximum value\",\"global_message\":\"Validation fails for maximum value\",\"global\":true},\"digits\":{\"value\":\"\",\"message\":\"Validation fails for limited digits\",\"global_message\":\"Validation fails for limited digits\",\"global\":true}},\"gc_onset\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\",\"global_message\":\"This field must contain numeric value\",\"global\":true},\"min\":{\"value\":\"\",\"message\":\"Validation fails for minimum value\",\"global_message\":\"Validation fails for minimum value\",\"global\":true},\"max\":{\"value\":\"\",\"message\":\"Validation fails for maximum value\",\"global_message\":\"Validation fails for maximum value\",\"global\":true},\"digits\":{\"value\":\"\",\"message\":\"Validation fails for limited digits\",\"global_message\":\"Validation fails for limited digits\",\"global\":true}},\"gc_percept\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\",\"global_message\":\"This field must contain numeric value\",\"global\":true},\"min\":{\"value\":\"\",\"message\":\"Validation fails for minimum value\",\"global_message\":\"Validation fails for minimum value\",\"global\":true},\"max\":{\"value\":\"\",\"message\":\"Validation fails for maximum value\",\"global_message\":\"Validation fails for maximum value\",\"global\":true},\"digits\":{\"value\":\"\",\"message\":\"Validation fails for limited digits\",\"global_message\":\"Validation fails for limited digits\",\"global\":true}},\"gc_context\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\",\"global_message\":\"This field must contain numeric value\",\"global\":true},\"min\":{\"value\":\"\",\"message\":\"Validation fails for minimum value\",\"global_message\":\"Validation fails for minimum value\",\"global\":true},\"max\":{\"value\":\"\",\"message\":\"Validation fails for maximum value\",\"global_message\":\"Validation fails for maximum value\",\"global\":true},\"digits\":{\"value\":\"\",\"message\":\"Validation fails for limited digits\",\"global_message\":\"Validation fails for limited digits\",\"global\":true}},\"gc_total\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\",\"global_message\":\"This field must contain numeric value\",\"global\":true},\"min\":{\"value\":\"\",\"message\":\"Validation fails for minimum value\",\"global_message\":\"Validation fails for minimum value\",\"global\":true},\"max\":{\"value\":\"\",\"message\":\"Validation fails for maximum value\",\"global_message\":\"Validation fails for maximum value\",\"global\":true},\"digits\":{\"value\":\"\",\"message\":\"Validation fails for limited digits\",\"global_message\":\"Validation fails for limited digits\",\"global\":true}},\"Hearing_Aid_Issues\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"hearing_aid_list[Which ear?]\":{\"required\":{\"value\":true,\"global\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\"}},\"hearing_aid_list[What is the main issue?]\":{\"required\":{\"value\":true,\"global\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\"}},\"hearing_aid_list[How old is the device?]\":{\"required\":{\"value\":true,\"global\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\"}},\"ha_base\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\",\"global_message\":\"This field must contain numeric value\",\"global\":true},\"min\":{\"value\":\"\",\"message\":\"Validation fails for minimum value\",\"global_message\":\"Validation fails for minimum value\",\"global\":true},\"max\":{\"value\":\"\",\"message\":\"Validation fails for maximum value\",\"global_message\":\"Validation fails for maximum value\",\"global\":true},\"digits\":{\"value\":\"\",\"message\":\"Validation fails for limited digits\",\"global_message\":\"Validation fails for limited digits\",\"global\":true}},\"ha_onset\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\",\"global_message\":\"This field must contain numeric value\",\"global\":true},\"min\":{\"value\":\"\",\"message\":\"Validation fails for minimum value\",\"global_message\":\"Validation fails for minimum value\",\"global\":true},\"max\":{\"value\":\"\",\"message\":\"Validation fails for maximum value\",\"global_message\":\"Validation fails for maximum value\",\"global\":true},\"digits\":{\"value\":\"\",\"message\":\"Validation fails for limited digits\",\"global_message\":\"Validation fails for limited digits\",\"global\":true}},\"ha_percept\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\",\"global_message\":\"This field must contain numeric value\",\"global\":true},\"min\":{\"value\":\"\",\"message\":\"Validation fails for minimum value\",\"global_message\":\"Validation fails for minimum value\",\"global\":true},\"max\":{\"value\":\"\",\"message\":\"Validation fails for maximum value\",\"global_message\":\"Validation fails for maximum value\",\"global\":true},\"digits\":{\"value\":\"\",\"message\":\"Validation fails for limited digits\",\"global_message\":\"Validation fails for limited digits\",\"global\":true}},\"ha_context\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\",\"global_message\":\"This field must contain numeric value\",\"global\":true},\"min\":{\"value\":\"\",\"message\":\"Validation fails for minimum value\",\"global_message\":\"Validation fails for minimum value\",\"global\":true},\"max\":{\"value\":\"\",\"message\":\"Validation fails for maximum value\",\"global_message\":\"Validation fails for maximum value\",\"global\":true},\"digits\":{\"value\":\"\",\"message\":\"Validation fails for limited digits\",\"global_message\":\"Validation fails for limited digits\",\"global\":true}},\"ha_total\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\",\"global_message\":\"This field must contain numeric value\",\"global\":true},\"min\":{\"value\":\"\",\"message\":\"Validation fails for minimum value\",\"global_message\":\"Validation fails for minimum value\",\"global\":true},\"max\":{\"value\":\"\",\"message\":\"Validation fails for maximum value\",\"global_message\":\"Validation fails for maximum value\",\"global\":true},\"digits\":{\"value\":\"\",\"message\":\"Validation fails for limited digits\",\"global_message\":\"Validation fails for limited digits\",\"global\":true}},\"Dizzy\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"dizzy_list[Which ear (if known)?]\":{\"required\":{\"value\":true,\"global\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\"}},\"dizzy_list[When did this start?]\":{\"required\":{\"value\":true,\"global\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\"}},\"dizzy_list[What does it feel like?]\":{\"required\":{\"value\":true,\"global\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\"}},\"dz_base\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\",\"global_message\":\"This field must contain numeric value\",\"global\":true},\"min\":{\"value\":\"\",\"message\":\"Validation fails for minimum value\",\"global_message\":\"Validation fails for minimum value\",\"global\":true},\"max\":{\"value\":\"\",\"message\":\"Validation fails for maximum value\",\"global_message\":\"Validation fails for maximum value\",\"global\":true},\"digits\":{\"value\":\"\",\"message\":\"Validation fails for limited digits\",\"global_message\":\"Validation fails for limited digits\",\"global\":true}},\"dz_onset\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\",\"global_message\":\"This field must contain numeric value\",\"global\":true},\"min\":{\"value\":\"\",\"message\":\"Validation fails for minimum value\",\"global_message\":\"Validation fails for minimum value\",\"global\":true},\"max\":{\"value\":\"\",\"message\":\"Validation fails for maximum value\",\"global_message\":\"Validation fails for maximum value\",\"global\":true},\"digits\":{\"value\":\"\",\"message\":\"Validation fails for limited digits\",\"global_message\":\"Validation fails for limited digits\",\"global\":true}},\"dz_percept\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\",\"global_message\":\"This field must contain numeric value\",\"global\":true},\"min\":{\"value\":\"\",\"message\":\"Validation fails for minimum value\",\"global_message\":\"Validation fails for minimum value\",\"global\":true},\"max\":{\"value\":\"\",\"message\":\"Validation fails for maximum value\",\"global_message\":\"Validation fails for maximum 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