{"id":29041,"date":"2018-09-28T15:16:37","date_gmt":"2018-09-28T19:16:37","guid":{"rendered":"http:\/\/unusual-kelp.flywheelsites.com\/?page_id=29041"},"modified":"2018-10-03T09:02:28","modified_gmt":"2018-10-03T13:02:28","slug":"are-you-at-risk-for-cognitive-decline-or-dementia","status":"publish","type":"page","link":"https:\/\/losgatosaudiology.com\/are-you-at-risk-for-cognitive-decline-or-dementia\/","title":{"rendered":"Are You at Risk for Cognitive Decline or Dementia?"},"content":{"rendered":"<p>[et_pb_section bb_built=&#8221;1&#8243; specialty=&#8221;off&#8221; next_background_color=&#8221;#000000&#8243; _builder_version=&#8221;3.4.1&#8243; custom_margin=&#8221;0px||0px|&#8221; custom_padding=&#8221;0px||0px|&#8221;][et_pb_row _builder_version=&#8221;3.4.1&#8243; border_width_bottom=&#8221;1px&#8221; border_color_bottom=&#8221;#cccccc&#8221; border_color_all=&#8221;#999999&#8243; border_style_all=&#8221;dashed&#8221; custom_padding=&#8221;30px||30px|&#8221; border_style_bottom=&#8221;solid&#8221;][et_pb_column type=&#8221;4_4&#8243;][et_pb_text admin_label=&#8221;Page title&#8221; _builder_version=&#8221;3.13&#8243; text_font=&#8221;|700|||||||&#8221; text_text_color=&#8221;#0062a6&#8243; text_font_size=&#8221;36px&#8221; module_class=&#8221;page-title&#8221;]<\/p>\n<h1>Are you at Risk for Cognitive Decline or Dementia?<\/h1>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section bb_built=&#8221;1&#8243; prev_background_color=&#8221;#000000&#8243; _builder_version=&#8221;3.4.1&#8243; custom_padding=&#8221;0px|||&#8221;][et_pb_row _builder_version=&#8221;3.4.1&#8243; custom_padding=&#8221;||0px|&#8221;][et_pb_column type=&#8221;4_4&#8243;][et_pb_text _builder_version=&#8221;3.13&#8243;]<\/p>\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_6' ><div id='gf_6' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_6' id='gform_6'  action='\/wp-json\/wp\/v2\/pages\/29041#gf_6' data-formid='6' novalidate><div id='gf_page_steps_6' class='gf_page_steps'><div id='gf_step_6_1' class='gf_step gf_step_active gf_step_first'><span class='gf_step_number'>1<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_6_2' class='gf_step gf_step_next gf_step_pending'><span class='gf_step_number'>2<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_6_3' class='gf_step gf_step_last gf_step_pending'><span class='gf_step_number'>3<\/span><span class='gf_step_label'><\/span><\/div><\/div> \r\n <input type='hidden' class='gforms-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/>\n                        <div class='gform-body gform_body'><div id='gform_page_6_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_6_1\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_1\" ><label class='gfield_label gform-field-label' >Are you over the age of 65?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_1'>\n\t\t\t<li class='gchoice gchoice_6_1_0'>\n\t\t\t\t<input name='input_1' type='radio' value='gquiz197854a3e'  id='choice_6_1_0'    \/>\n\t\t\t\t<label for='choice_6_1_0' id='label_6_1_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_1_1'>\n\t\t\t\t<input name='input_1' type='radio' value='gquiz1060740ca'  id='choice_6_1_1'    \/>\n\t\t\t\t<label for='choice_6_1_1' id='label_6_1_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_38\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_38\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_5\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_5\" ><label class='gfield_label gform-field-label' >Do either of your parents, grandparents, aunts, or uncles have Alzheimer\u2019s or some other form of dementia?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_5'>\n\t\t\t<li class='gchoice gchoice_6_5_0'>\n\t\t\t\t<input name='input_5' type='radio' value='gquiz197854a3e'  id='choice_6_5_0'    \/>\n\t\t\t\t<label for='choice_6_5_0' id='label_6_5_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_5_1'>\n\t\t\t\t<input name='input_5' type='radio' value='gquiz1060740ca'  id='choice_6_5_1'    \/>\n\t\t\t\t<label for='choice_6_5_1' id='label_6_5_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_39\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_39\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_6\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_6\" ><label class='gfield_label gform-field-label' >Do either of your parents, grandparents, aunts, or uncles had a stroke or heart attack?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_6'>\n\t\t\t<li class='gchoice gchoice_6_6_0'>\n\t\t\t\t<input name='input_6' type='radio' value='gquiz197854a3e'  id='choice_6_6_0'    \/>\n\t\t\t\t<label for='choice_6_6_0' id='label_6_6_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_6_1'>\n\t\t\t\t<input name='input_6' type='radio' value='gquiz1060740ca'  id='choice_6_6_1'    \/>\n\t\t\t\t<label for='choice_6_6_1' id='label_6_6_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_40\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_40\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_7\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_7\" ><label class='gfield_label gform-field-label' >Is there a family history of heart or vascular problems?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_7'>\n\t\t\t<li class='gchoice gchoice_6_7_0'>\n\t\t\t\t<input name='input_7' type='radio' value='gquiz197854a3e'  id='choice_6_7_0'    \/>\n\t\t\t\t<label for='choice_6_7_0' id='label_6_7_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_7_1'>\n\t\t\t\t<input name='input_7' type='radio' value='gquiz78c146d7b'  id='choice_6_7_1'    \/>\n\t\t\t\t<label for='choice_6_7_1' id='label_6_7_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_41\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_41\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_8\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_8\" ><label class='gfield_label gform-field-label' >Do you live a relatively sedentary lifestyle with little exercise (Less than 15 minutes a day that requires you to breath harder than normal)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_8'>\n\t\t\t<li class='gchoice gchoice_6_8_0'>\n\t\t\t\t<input name='input_8' type='radio' value='gquiz197854a3e'  id='choice_6_8_0'    \/>\n\t\t\t\t<label for='choice_6_8_0' id='label_6_8_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_8_1'>\n\t\t\t\t<input name='input_8' type='radio' value='gquiz1060740ca'  id='choice_6_8_1'    \/>\n\t\t\t\t<label for='choice_6_8_1' id='label_6_8_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_42\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_42\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_9\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_9\" ><label class='gfield_label gform-field-label' >Has a doctor ever told you that you were diabetic, borderline diabetic, or that you have insulin resistance?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_9'>\n\t\t\t<li class='gchoice gchoice_6_9_0'>\n\t\t\t\t<input name='input_9' type='radio' value='gquiz197854a3e'  id='choice_6_9_0'    \/>\n\t\t\t\t<label for='choice_6_9_0' id='label_6_9_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_9_1'>\n\t\t\t\t<input name='input_9' type='radio' value='gquiz1060740ca'  id='choice_6_9_1'    \/>\n\t\t\t\t<label for='choice_6_9_1' id='label_6_9_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_43\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_43\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_10\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_10\" ><label class='gfield_label gform-field-label' >Do you have high blood pressure?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_10'>\n\t\t\t<li class='gchoice gchoice_6_10_0'>\n\t\t\t\t<input name='input_10' type='radio' value='gquiz197854a3e'  id='choice_6_10_0'    \/>\n\t\t\t\t<label for='choice_6_10_0' id='label_6_10_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_10_1'>\n\t\t\t\t<input name='input_10' type='radio' value='gquiz1060740ca'  id='choice_6_10_1'    \/>\n\t\t\t\t<label for='choice_6_10_1' id='label_6_10_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_6_29' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"2\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"2\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_2' class='gform_page' data-js='page-field-id-29' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_6_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_6_11\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_11\" ><label class='gfield_label gform-field-label' >Do you sometimes have difficulty hearing (If in doubt ask your partner)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_11'>\n\t\t\t<li class='gchoice gchoice_6_11_0'>\n\t\t\t\t<input name='input_11' type='radio' value='gquiz197854a3e'  id='choice_6_11_0'    \/>\n\t\t\t\t<label for='choice_6_11_0' id='label_6_11_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_11_1'>\n\t\t\t\t<input name='input_11' type='radio' value='gquiz1060740ca'  id='choice_6_11_1'    \/>\n\t\t\t\t<label for='choice_6_11_1' id='label_6_11_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_44\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_44\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_12\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_12\" ><label class='gfield_label gform-field-label' >Do you have thyroid problems or difficulty staying warm?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_12'>\n\t\t\t<li class='gchoice gchoice_6_12_0'>\n\t\t\t\t<input name='input_12' type='radio' value='gquiz197854a3e'  id='choice_6_12_0'    \/>\n\t\t\t\t<label for='choice_6_12_0' id='label_6_12_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_12_1'>\n\t\t\t\t<input name='input_12' type='radio' value='gquiz1060740ca'  id='choice_6_12_1'    \/>\n\t\t\t\t<label for='choice_6_12_1' id='label_6_12_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_45\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_45\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_13\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_13\" ><label class='gfield_label gform-field-label' >Have you experienced prolonged stress or depression?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_13'>\n\t\t\t<li class='gchoice gchoice_6_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='gquiz197854a3e'  id='choice_6_13_0'    \/>\n\t\t\t\t<label for='choice_6_13_0' id='label_6_13_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='gquiz1060740ca'  id='choice_6_13_1'    \/>\n\t\t\t\t<label for='choice_6_13_1' id='label_6_13_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_46\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_46\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_14\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_14\" ><label class='gfield_label gform-field-label' >Do you smoke or have you smoked tobacco products?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_14'>\n\t\t\t<li class='gchoice gchoice_6_14_0'>\n\t\t\t\t<input name='input_14' type='radio' value='gquiz197854a3e'  id='choice_6_14_0'    \/>\n\t\t\t\t<label for='choice_6_14_0' id='label_6_14_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_14_1'>\n\t\t\t\t<input name='input_14' type='radio' value='gquiz1060740ca'  id='choice_6_14_1'    \/>\n\t\t\t\t<label for='choice_6_14_1' id='label_6_14_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_47\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_47\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_15\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_15\" ><label class='gfield_label gform-field-label' >Do you drink 8 oz of drinks containing alcohol or diet sodas daily?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_15'>\n\t\t\t<li class='gchoice gchoice_6_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='gquiz197854a3e'  id='choice_6_15_0'    \/>\n\t\t\t\t<label for='choice_6_15_0' id='label_6_15_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='gquiz1060740ca'  id='choice_6_15_1'    \/>\n\t\t\t\t<label for='choice_6_15_1' id='label_6_15_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_48\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_48\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_17\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_17\" ><label class='gfield_label gform-field-label' >Do you have difficulty sleeping at night?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_17'>\n\t\t\t<li class='gchoice gchoice_6_17_0'>\n\t\t\t\t<input name='input_17' type='radio' value='gquiz197854a3e'  id='choice_6_17_0'    \/>\n\t\t\t\t<label for='choice_6_17_0' id='label_6_17_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_17_1'>\n\t\t\t\t<input name='input_17' type='radio' value='gquiz1060740ca'  id='choice_6_17_1'    \/>\n\t\t\t\t<label for='choice_6_17_1' id='label_6_17_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_49\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_49\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_19\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_19\" ><label class='gfield_label gform-field-label' >Are you on a statin\u00a8 pain\u00a8 sleep\u00a8 hormone or depression medication?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_19'>\n\t\t\t<li class='gchoice gchoice_6_19_0'>\n\t\t\t\t<input name='input_19' type='radio' value='gquiz197854a3e'  id='choice_6_19_0'    \/>\n\t\t\t\t<label for='choice_6_19_0' id='label_6_19_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_19_1'>\n\t\t\t\t<input name='input_19' type='radio' value='gquiz1060740ca'  id='choice_6_19_1'    \/>\n\t\t\t\t<label for='choice_6_19_1' id='label_6_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_51\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_51\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_20\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_20\" ><label class='gfield_label gform-field-label' >Are you retired without a driving purpose?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_20'>\n\t\t\t<li class='gchoice gchoice_6_20_0'>\n\t\t\t\t<input name='input_20' type='radio' value='gquiz197854a3e'  id='choice_6_20_0'    \/>\n\t\t\t\t<label for='choice_6_20_0' id='label_6_20_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_20_1'>\n\t\t\t\t<input name='input_20' type='radio' value='gquiz1060740ca'  id='choice_6_20_1'    \/>\n\t\t\t\t<label for='choice_6_20_1' id='label_6_20_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_52\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_52\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_21\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_21\" ><label class='gfield_label gform-field-label' >Do you forget more than you used to or find it hard at times to recall the right words or names of people you know well?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_21'>\n\t\t\t<li class='gchoice gchoice_6_21_0'>\n\t\t\t\t<input name='input_21' type='radio' value='gquiz197854a3e'  id='choice_6_21_0'    \/>\n\t\t\t\t<label for='choice_6_21_0' id='label_6_21_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_21_1'>\n\t\t\t\t<input name='input_21' type='radio' value='gquiz1060740ca'  id='choice_6_21_1'    \/>\n\t\t\t\t<label for='choice_6_21_1' id='label_6_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_56' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"1\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"1\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_6_56' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"3\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"3\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_3' class='gform_page' data-js='page-field-id-56' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_6_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_6_57\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_57\" ><h2 class=\"gsection_title\">Please Enter Your Information Below<\/h2><div class='gsection_description' id='gfield_description_6_57'>Entering your information below will calculate your results and allow us to email you more in-depth information.<\/div><\/li><li id=\"field_6_53\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_53\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_6_53'>\n                            \n                            <span id='input_6_53_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_53.3' id='input_6_53_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_53_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_6_53_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_53.6' id='input_6_53_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_53_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_6_55\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_55\" ><label class='gfield_label gform-field-label' for='input_6_55'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_55' id='input_6_55' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_54\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_54\" ><label class='gfield_label gform-field-label' for='input_6_54'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_54' id='input_6_54' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><\/ul><\/div>\n        <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_6' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='if(window[\"gf_submitting_6\"]){return false;}  if( !jQuery(\"#gform_6\")[0].checkValidity || jQuery(\"#gform_6\")[0].checkValidity()){window[\"gf_submitting_6\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_6\"]){return false;} if( !jQuery(\"#gform_6\")[0].checkValidity || jQuery(\"#gform_6\")[0].checkValidity()){window[\"gf_submitting_6\"]=true;}  jQuery(\"#gform_6\").trigger(\"submit\",[true]); }' \/> <input type='submit' id='gform_submit_button_6' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_6\"]){return false;}  if( !jQuery(\"#gform_6\")[0].checkValidity || jQuery(\"#gform_6\")[0].checkValidity()){window[\"gf_submitting_6\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_6\"]){return false;} if( !jQuery(\"#gform_6\")[0].checkValidity || jQuery(\"#gform_6\")[0].checkValidity()){window[\"gf_submitting_6\"]=true;}  jQuery(\"#gform_6\").trigger(\"submit\",[true]); }' \/> <input type='hidden' name='gform_ajax' value='form_id=6&amp;title=&amp;description=&amp;tabindex=0&amp;theme=legacy' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_6' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='6' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_6' value='WyJbXSIsIjU5NDhkYTk2MTRmZDU5NTI2OTE1OGQ0MzIyZWRlMDdjIl0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_6' id='gform_target_page_number_6' value='2' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_6' id='gform_source_page_number_6' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/div><\/div>\n                        <\/form>\n                        <\/div>\n\t\t                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_6' id='gform_ajax_frame_6' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n\t\t                <script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 6, 'https:\/\/losgatosaudiology.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_6').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_6');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_6').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_6').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_6').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_6').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_6').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_6').val();gformInitSpinner( 6, 'https:\/\/losgatosaudiology.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [6, current_page]);window['gf_submitting_6'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_6').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_6').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [6]);window['gf_submitting_6'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_6').text());}else{jQuery('#gform_6').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"6\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);                if (event && event.defaultPrevented) {                return;         }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_6\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_6\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_6\" );        let postRenderFired = false;                function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            jQuery( document ).trigger( 'gform_post_render', [6, current_page] );            gform.utils.trigger( { event: 'gform\/postRender', native: false, data: { formId: 6, currentPage: current_page } } );       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       if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} ); \n\/* ]]> *\/\n<\/script>\n\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Are you at Risk for Cognitive Decline or Dementia? \n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='1' id='gform_wrapper_6' ><div id='gf_6' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_6' id='gform_6'  action='\/wp-json\/wp\/v2\/pages\/29041#gf_6' data-formid='6' novalidate><div id='gf_page_steps_6' class='gf_page_steps'><div id='gf_step_6_1' class='gf_step gf_step_active gf_step_first'><span class='gf_step_number'>1<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_6_2' class='gf_step gf_step_next gf_step_pending'><span class='gf_step_number'>2<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_6_3' class='gf_step gf_step_last gf_step_pending'><span class='gf_step_number'>3<\/span><span class='gf_step_label'><\/span><\/div><\/div> \r\n <input type='hidden' class='gforms-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/>\n                        <div class='gform-body gform_body'><div id='gform_page_6_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_6_1\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_1\" ><label class='gfield_label gform-field-label' >Are you over the age of 65?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_1'>\n\t\t\t<li class='gchoice gchoice_6_1_0'>\n\t\t\t\t<input name='input_1' type='radio' value='gquiz197854a3e'  id='choice_6_1_0'    \/>\n\t\t\t\t<label for='choice_6_1_0' id='label_6_1_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_1_1'>\n\t\t\t\t<input name='input_1' type='radio' value='gquiz1060740ca'  id='choice_6_1_1'    \/>\n\t\t\t\t<label for='choice_6_1_1' id='label_6_1_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_38\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_38\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_5\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_5\" ><label class='gfield_label gform-field-label' >Do either of your parents, grandparents, aunts, or uncles have Alzheimer\u2019s or some other form of dementia?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_5'>\n\t\t\t<li class='gchoice gchoice_6_5_0'>\n\t\t\t\t<input name='input_5' type='radio' value='gquiz197854a3e'  id='choice_6_5_0'    \/>\n\t\t\t\t<label for='choice_6_5_0' id='label_6_5_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_5_1'>\n\t\t\t\t<input name='input_5' type='radio' value='gquiz1060740ca'  id='choice_6_5_1'    \/>\n\t\t\t\t<label for='choice_6_5_1' id='label_6_5_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_39\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_39\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_6\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_6\" ><label class='gfield_label gform-field-label' >Do either of your parents, grandparents, aunts, or uncles had a stroke or heart attack?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_6'>\n\t\t\t<li class='gchoice gchoice_6_6_0'>\n\t\t\t\t<input name='input_6' type='radio' value='gquiz197854a3e'  id='choice_6_6_0'    \/>\n\t\t\t\t<label for='choice_6_6_0' id='label_6_6_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_6_1'>\n\t\t\t\t<input name='input_6' type='radio' value='gquiz1060740ca'  id='choice_6_6_1'    \/>\n\t\t\t\t<label for='choice_6_6_1' id='label_6_6_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_40\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_40\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_7\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_7\" ><label class='gfield_label gform-field-label' >Is there a family history of heart or vascular problems?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_7'>\n\t\t\t<li class='gchoice gchoice_6_7_0'>\n\t\t\t\t<input name='input_7' type='radio' value='gquiz197854a3e'  id='choice_6_7_0'    \/>\n\t\t\t\t<label for='choice_6_7_0' id='label_6_7_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_7_1'>\n\t\t\t\t<input name='input_7' type='radio' value='gquiz78c146d7b'  id='choice_6_7_1'    \/>\n\t\t\t\t<label for='choice_6_7_1' id='label_6_7_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_41\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_41\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_8\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_8\" ><label class='gfield_label gform-field-label' >Do you live a relatively sedentary lifestyle with little exercise (Less than 15 minutes a day that requires you to breath harder than normal)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_8'>\n\t\t\t<li class='gchoice gchoice_6_8_0'>\n\t\t\t\t<input name='input_8' type='radio' value='gquiz197854a3e'  id='choice_6_8_0'    \/>\n\t\t\t\t<label for='choice_6_8_0' id='label_6_8_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_8_1'>\n\t\t\t\t<input name='input_8' type='radio' value='gquiz1060740ca'  id='choice_6_8_1'    \/>\n\t\t\t\t<label for='choice_6_8_1' id='label_6_8_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_42\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_42\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_9\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_9\" ><label class='gfield_label gform-field-label' >Has a doctor ever told you that you were diabetic, borderline diabetic, or that you have insulin resistance?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_9'>\n\t\t\t<li class='gchoice gchoice_6_9_0'>\n\t\t\t\t<input name='input_9' type='radio' value='gquiz197854a3e'  id='choice_6_9_0'    \/>\n\t\t\t\t<label for='choice_6_9_0' id='label_6_9_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_9_1'>\n\t\t\t\t<input name='input_9' type='radio' value='gquiz1060740ca'  id='choice_6_9_1'    \/>\n\t\t\t\t<label for='choice_6_9_1' id='label_6_9_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_43\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_43\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_10\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_10\" ><label class='gfield_label gform-field-label' >Do you have high blood pressure?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_10'>\n\t\t\t<li class='gchoice gchoice_6_10_0'>\n\t\t\t\t<input name='input_10' type='radio' value='gquiz197854a3e'  id='choice_6_10_0'    \/>\n\t\t\t\t<label for='choice_6_10_0' id='label_6_10_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_10_1'>\n\t\t\t\t<input name='input_10' type='radio' value='gquiz1060740ca'  id='choice_6_10_1'    \/>\n\t\t\t\t<label for='choice_6_10_1' id='label_6_10_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_6_29' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"2\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"2\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_2' class='gform_page' data-js='page-field-id-29' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_6_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_6_11\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_11\" ><label class='gfield_label gform-field-label' >Do you sometimes have difficulty hearing (If in doubt ask your partner)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_11'>\n\t\t\t<li class='gchoice gchoice_6_11_0'>\n\t\t\t\t<input name='input_11' type='radio' value='gquiz197854a3e'  id='choice_6_11_0'    \/>\n\t\t\t\t<label for='choice_6_11_0' id='label_6_11_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_11_1'>\n\t\t\t\t<input name='input_11' type='radio' value='gquiz1060740ca'  id='choice_6_11_1'    \/>\n\t\t\t\t<label for='choice_6_11_1' id='label_6_11_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_44\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_44\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_12\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_12\" ><label class='gfield_label gform-field-label' >Do you have thyroid problems or difficulty staying warm?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_12'>\n\t\t\t<li class='gchoice gchoice_6_12_0'>\n\t\t\t\t<input name='input_12' type='radio' value='gquiz197854a3e'  id='choice_6_12_0'    \/>\n\t\t\t\t<label for='choice_6_12_0' id='label_6_12_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_12_1'>\n\t\t\t\t<input name='input_12' type='radio' value='gquiz1060740ca'  id='choice_6_12_1'    \/>\n\t\t\t\t<label for='choice_6_12_1' id='label_6_12_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_45\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_45\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_13\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_13\" ><label class='gfield_label gform-field-label' >Have you experienced prolonged stress or depression?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_13'>\n\t\t\t<li class='gchoice gchoice_6_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='gquiz197854a3e'  id='choice_6_13_0'    \/>\n\t\t\t\t<label for='choice_6_13_0' id='label_6_13_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='gquiz1060740ca'  id='choice_6_13_1'    \/>\n\t\t\t\t<label for='choice_6_13_1' id='label_6_13_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_46\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_46\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_14\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_14\" ><label class='gfield_label gform-field-label' >Do you smoke or have you smoked tobacco products?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_14'>\n\t\t\t<li class='gchoice gchoice_6_14_0'>\n\t\t\t\t<input name='input_14' type='radio' value='gquiz197854a3e'  id='choice_6_14_0'    \/>\n\t\t\t\t<label for='choice_6_14_0' id='label_6_14_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_14_1'>\n\t\t\t\t<input name='input_14' type='radio' value='gquiz1060740ca'  id='choice_6_14_1'    \/>\n\t\t\t\t<label for='choice_6_14_1' id='label_6_14_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_47\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_47\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_15\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_15\" ><label class='gfield_label gform-field-label' >Do you drink 8 oz of drinks containing alcohol or diet sodas daily?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_15'>\n\t\t\t<li class='gchoice gchoice_6_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='gquiz197854a3e'  id='choice_6_15_0'    \/>\n\t\t\t\t<label for='choice_6_15_0' id='label_6_15_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='gquiz1060740ca'  id='choice_6_15_1'    \/>\n\t\t\t\t<label for='choice_6_15_1' id='label_6_15_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_48\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_48\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_17\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_17\" ><label class='gfield_label gform-field-label' >Do you have difficulty sleeping at night?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_17'>\n\t\t\t<li class='gchoice gchoice_6_17_0'>\n\t\t\t\t<input name='input_17' type='radio' value='gquiz197854a3e'  id='choice_6_17_0'    \/>\n\t\t\t\t<label for='choice_6_17_0' id='label_6_17_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_17_1'>\n\t\t\t\t<input name='input_17' type='radio' value='gquiz1060740ca'  id='choice_6_17_1'    \/>\n\t\t\t\t<label for='choice_6_17_1' id='label_6_17_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_49\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_49\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_19\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_19\" ><label class='gfield_label gform-field-label' >Are you on a statin\u00a8 pain\u00a8 sleep\u00a8 hormone or depression medication?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_19'>\n\t\t\t<li class='gchoice gchoice_6_19_0'>\n\t\t\t\t<input name='input_19' type='radio' value='gquiz197854a3e'  id='choice_6_19_0'    \/>\n\t\t\t\t<label for='choice_6_19_0' id='label_6_19_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_19_1'>\n\t\t\t\t<input name='input_19' type='radio' value='gquiz1060740ca'  id='choice_6_19_1'    \/>\n\t\t\t\t<label for='choice_6_19_1' id='label_6_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_51\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_51\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_20\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_20\" ><label class='gfield_label gform-field-label' >Are you retired without a driving purpose?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_20'>\n\t\t\t<li class='gchoice gchoice_6_20_0'>\n\t\t\t\t<input name='input_20' type='radio' value='gquiz197854a3e'  id='choice_6_20_0'    \/>\n\t\t\t\t<label for='choice_6_20_0' id='label_6_20_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_20_1'>\n\t\t\t\t<input name='input_20' type='radio' value='gquiz1060740ca'  id='choice_6_20_1'    \/>\n\t\t\t\t<label for='choice_6_20_1' id='label_6_20_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_52\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_52\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_6_21\" class=\"gfield gfield--type-quiz gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_21\" ><label class='gfield_label gform-field-label' >Do you forget more than you used to or find it hard at times to recall the right words or names of people you know well?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_21'>\n\t\t\t<li class='gchoice gchoice_6_21_0'>\n\t\t\t\t<input name='input_21' type='radio' value='gquiz197854a3e'  id='choice_6_21_0'    \/>\n\t\t\t\t<label for='choice_6_21_0' id='label_6_21_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_21_1'>\n\t\t\t\t<input name='input_21' type='radio' value='gquiz1060740ca'  id='choice_6_21_1'    \/>\n\t\t\t\t<label for='choice_6_21_1' id='label_6_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_56' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"1\");  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field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_57\" ><h2 class=\"gsection_title\">Please Enter Your Information Below<\/h2><div class='gsection_description' id='gfield_description_6_57'>Entering your information below will calculate your results and allow us to email you more in-depth information.<\/div><\/li><li id=\"field_6_53\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_53\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 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