{"id":1134,"date":"2020-05-02T15:00:31","date_gmt":"2020-05-02T13:00:31","guid":{"rendered":"https:\/\/cabinetdupesage.be\/?page_id=1134"},"modified":"2020-05-02T15:00:50","modified_gmt":"2020-05-02T13:00:50","slug":"formulaire-nouveau-patient","status":"publish","type":"page","link":"https:\/\/cabinetdupesage.be\/index.php\/formulaire-nouveau-patient\/","title":{"rendered":"Formulaire nouveau patient"},"content":{"rendered":"\n<p>Afin de mieux vous connaitre et ainsi de pouvoir vous soigner dans les meilleures conditions, nous vous demandons de bien vouloir remplir ce formulaire<\/p>\n\n\n\n<p class=\"has-text-color has-vivid-red-color\"><strong>Ce questionnaire m\u00e9dical doit \u00eatre actualis\u00e9 en permanence , nous vous demandons donc de nous signaler directement toute modification \u00e9ventuelle de votre \u00e9tat de sant\u00e9.<\/strong><\/p>\n\n\n\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f1133-o1\" lang=\"fr-FR\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php\/wp-json\/wp\/v2\/pages\/1134#wpcf7-f1133-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Formulaire de contact\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"1133\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.9.5\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"fr_FR\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f1133-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<p><label> Titre<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"titre\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"titre\"><option value=\"Mademoiselle\">Mademoiselle<\/option><option value=\"Madame\">Madame<\/option><option value=\"Monsieur\">Monsieur<\/option><\/select><\/span><\/label><br \/>\n<label> Votre nom (de jeune fille pour les femmes)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span> <\/label><br \/>\n<label> Votre pr\u00e9nom<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-firstname\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-firstname\" \/><\/span> <\/label><br \/>\n<label> Votre date de naissance<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"datedenaissance\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"datedenaissance\" \/><\/span>] <\/label><br \/>\n<label> Votre adresse de messagerie<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-mail\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-mail\" \/><\/span> <\/label><br \/>\n<label> GSM<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-phone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-phone\" \/><\/span> <\/label><br \/>\n<label> Num\u00e9ro de registre national (au verso de votre carte d'identit\u00e9, commence par votre date de naissance \u00e0 l'envers)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-niss\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-niss\" \/><\/span> <\/label><br \/>\n<label> Eventuelle assurance dentaire compl\u00e9mentaire autre que la mutuelle<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"assurance\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"assurance\" \/><\/span> <\/label>\n<\/p>\n<p>Votre adresse\n<\/p>\n<p>Rue<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"rue\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"rue\" \/><\/span><br \/>\nNum\u00e9ro<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"numero\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"numero\" \/><\/span><br \/>\nCode postal<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"codepostal\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"codepostal\" \/><\/span><br \/>\nCommune<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"commune\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"commune\" \/><\/span><br \/>\nPays<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pays\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pays\" \/><\/span>\n<\/p>\n<p>Questionnaire de sant\u00e9 (confidentiel)\n<\/p>\n<p>Nom du m\u00e9decin traitant<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"medecintraitant\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"medecintraitant\" \/><\/span><br \/>\nT\u00e9l\u00e9phone du m\u00e9decin traitant<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"telmedecintraitant\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"telmedecintraitant\" \/><\/span>\n<\/p>\n<p>Etes-vous en bon \u00e9tat de sant\u00e9 g\u00e9n\u00e9rale ?<span class=\"wpcf7-form-control-wrap\" data-name=\"sante\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"sante\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"sante\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span><br \/>\nSi NON, merci de pr\u00e9ciser<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"santeplus\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"santeplus\"><\/textarea><\/span><br \/>\nEtes-vous allergie ou supportez-vous mal une substance ou un m\u00e9dicament ? (Ex: Penicilline) <span class=\"wpcf7-form-control-wrap\" data-name=\"allergie\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"allergie\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"allergie\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span><br \/>\nSi OUI, merci de pr\u00e9ciser<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"allergieplus\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"allergieplus\"><\/textarea><\/span>\n<\/p>\n<p>Prenez-vous de mani\u00e8re r\u00e9guli\u00e8re des m\u00e9dicaments ? <span class=\"wpcf7-form-control-wrap\" data-name=\"medicament\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"medicament\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"medicament\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span><br \/>\nSi OUI, lesquels et pourquoi ?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"medicamentplus\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"medicamentplus\"><\/textarea><\/span>\n<\/p>\n<p>Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 gravement malade ou op\u00e9r\u00e9 (au niveau du visage) ? <span class=\"wpcf7-form-control-wrap\" data-name=\"operation\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"operation\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"operation\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span><br \/>\nSi OUI, merci d'expliquer ?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"operationplus\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"operationplus\"><\/textarea><\/span>\n<\/p>\n<p>Etes-vous fumeur ? <span class=\"wpcf7-form-control-wrap\" data-name=\"fumeur\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"fumeur\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"fumeur\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span><br \/>\nSi OUI, combien de cigarettes par jour en moyenne ?<span class=\"wpcf7-form-control-wrap\" data-name=\"cigarette\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" min=\"0\" max=\"40\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"cigarette\" \/><\/span>\n<\/p>\n<p>Mademoiselle, Madame, \u00eates vous enceinte ? <span class=\"wpcf7-form-control-wrap\" data-name=\"enceinte\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"enceinte\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"enceinte\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"enceinte\" value=\"peut-\u00eatre\" \/><span class=\"wpcf7-list-item-label\">peut-\u00eatre<\/span><\/span><\/span><\/span><br \/>\nSi oui (f\u00e9licitations !), depuis combien de mois ? <span class=\"wpcf7-form-control-wrap\" data-name=\"enceintemois\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" min=\"0\" max=\"9\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"enceintemois\" \/><\/span><br \/>\nAllaitez-vous ? <span class=\"wpcf7-form-control-wrap\" data-name=\"allaitement\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"allaitement\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"allaitement\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Avez-vous d\u00e9j\u00e0 eu une h\u00e9morragie n\u00e9cessitant un traitement ? <span class=\"wpcf7-form-control-wrap\" data-name=\"hemorragie\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"hemorragie\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"hemorragie\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span><br \/>\nEtes-vous sujet \u00e0 des malaises, naus\u00e9es, vertiges, pertes de connaissances ? <span class=\"wpcf7-form-control-wrap\" data-name=\"malaises\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"malaises\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"malaises\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Avez-vous d\u00e9j\u00e0 eu des probl\u00e8mes particuliers avec vos soins dentaires ? <span class=\"wpcf7-form-control-wrap\" data-name=\"problemeparticulier\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"problemeparticulier\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"problemeparticulier\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span><br \/>\nSi OUI, merci de sp\u00e9cifier<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"problemeparticulierplus\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"problemeparticulierplus\"><\/textarea><\/span>\n<\/p>\n<p>Etes-vous porteur d'une valve cardiaque artificielle ? <span class=\"wpcf7-form-control-wrap\" data-name=\"valvecardiaque\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"valvecardiaque\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"valvecardiaque\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Souffrez-vous ou avez-vous souffert de:<br \/>\ntroubles cardiaques<span class=\"wpcf7-form-control-wrap\" data-name=\"troubles\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"troubles\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"troubles\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span><br \/>\nhypertension<span class=\"wpcf7-form-control-wrap\" data-name=\"hypertension\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"hypertension\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"hypertension\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span><br \/>\nhypotension<span class=\"wpcf7-form-control-wrap\" data-name=\"hypotension\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"hypotension\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"hypotension\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span><br \/>\nasthme<span class=\"wpcf7-form-control-wrap\" data-name=\"asthme\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"asthme\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"asthme\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span><br \/>\nmaladie du sang<span class=\"wpcf7-form-control-wrap\" data-name=\"maladiedusang\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"maladiedusang\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"maladiedusang\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span><br \/>\nmaladie du foie<span class=\"wpcf7-form-control-wrap\" data-name=\"maladiefoie\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"maladiefoie\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"maladiefoie\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span><br \/>\ndiab\u00e8te<span class=\"wpcf7-form-control-wrap\" data-name=\"diabete\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"diabete\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"diabete\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span><br \/>\nrhumatisme articulaire aigu<span class=\"wpcf7-form-control-wrap\" data-name=\"raa\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"raa\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"raa\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span><br \/>\nh\u00e9patite<span class=\"wpcf7-form-control-wrap\" data-name=\"hepatite\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"hepatite\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"hepatite\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span><br \/>\nmaladie cardiovasculaire<span class=\"wpcf7-form-control-wrap\" data-name=\"maladiecardiovasculaire\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"maladiecardiovasculaire\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"maladiecardiovasculaire\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span><br \/>\nmaladie de l'estomac<span class=\"wpcf7-form-control-wrap\" data-name=\"maladieestomac\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"maladieestomac\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"maladieestomac\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span><br \/>\nmaladie des reins<span class=\"wpcf7-form-control-wrap\" data-name=\"maladiereins\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"maladiereins\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"maladiereins\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span><br \/>\n\u00e9pilepsie<span class=\"wpcf7-form-control-wrap\" data-name=\"epilepsie\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"epilepsie\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"epilepsie\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span><br \/>\nmaladie de la glande thyro\u00efde<span class=\"wpcf7-form-control-wrap\" data-name=\"glandethyroide\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"glandethyroide\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"glandethyroide\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span><br \/>\nmaladie des poumons<span class=\"wpcf7-form-control-wrap\" data-name=\"poumons\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"poumons\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"poumons\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span><br \/>\nd\u00e9ficit immunitaire<span class=\"wpcf7-form-control-wrap\" data-name=\"deficitimmunitaire\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"deficitimmunitaire\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"deficitimmunitaire\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span><br \/>\nHIV<span class=\"wpcf7-form-control-wrap\" data-name=\"hiv\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"hiv[]\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"hiv[]\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span><br \/>\ncancer<span class=\"wpcf7-form-control-wrap\" data-name=\"cancer\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"cancer\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"cancer\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span><br \/>\narthrose<span class=\"wpcf7-form-control-wrap\" data-name=\"arthrose\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"arthrose\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"arthrose\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span><br \/>\ntuberculose<span class=\"wpcf7-form-control-wrap\" data-name=\"tuberculose\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"tuberculose\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"tuberculose\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Avez-vous d'autres informations m\u00e9dicales ou autres \u00e0 nous communiquer ?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"infosplus\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"infosplus\"><\/textarea><\/span>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Envoyer\" \/>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n","protected":false},"excerpt":{"rendered":"<p>Afin de mieux vous connaitre et ainsi de pouvoir vous soigner dans les meilleures conditions, nous vous demandons de bien [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"om_disable_all_campaigns":false,"_lmt_disableupdate":"","_lmt_disable":"","_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"_uf_show_specific_survey":0,"_uf_disable_surveys":false,"footnotes":""},"class_list":["post-1134","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/cabinetdupesage.be\/index.php\/wp-json\/wp\/v2\/pages\/1134","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/cabinetdupesage.be\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/cabinetdupesage.be\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/cabinetdupesage.be\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/cabinetdupesage.be\/index.php\/wp-json\/wp\/v2\/comments?post=1134"}],"version-history":[{"count":4,"href":"https:\/\/cabinetdupesage.be\/index.php\/wp-json\/wp\/v2\/pages\/1134\/revisions"}],"predecessor-version":[{"id":1138,"href":"https:\/\/cabinetdupesage.be\/index.php\/wp-json\/wp\/v2\/pages\/1134\/revisions\/1138"}],"wp:attachment":[{"href":"https:\/\/cabinetdupesage.be\/index.php\/wp-json\/wp\/v2\/media?parent=1134"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}