{"id":3810,"date":"2021-05-17T15:40:18","date_gmt":"2021-05-17T15:40:18","guid":{"rendered":"https:\/\/coi.iris.rt5.ca\/?page_id=3810"},"modified":"2021-05-17T19:40:59","modified_gmt":"2021-05-17T19:40:59","slug":"follow-up-form-intra","status":"publish","type":"page","link":"https:\/\/coi.iris.rt5.ca\/en\/follow-up-form-intra\/","title":{"rendered":"Follow up form intra"},"content":{"rendered":"<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_20' ><form method='post' enctype='multipart\/form-data'  id='gform_20'  action='\/en\/wp-json\/wp\/v2\/pages\/3810' data-formid='20' >\n                        <div class='gform-body gform_body'><ul id='gform_fields_20' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_20_113\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_113\"><h1 style=\"text-align: center; padding-bottom: 1rem;\">Post-operative evaluation form - Intraocular surgery<\/h1><\/li><li id=\"field_20_31\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_31\"><h2 class=\"gsection_title\">Identification<\/h2><\/li><li id=\"field_20_34\"  class=\"gfield gfield--type-text gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_34\"><label class='gfield_label gform-field-label' for='input_20_34' >Last name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_20_34' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_35\"  class=\"gfield gfield--type-text gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_35\"><label class='gfield_label gform-field-label' for='input_20_35' >First name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_20_35' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_9\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_9\"><label class='gfield_label gform-field-label' for='input_20_9' >Follow-up date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_9' id='input_20_9' type='text' value='' class='datepicker gform-datepicker ymd_dash datepicker_with_icon gdatepicker_with_icon'   placeholder='yyyy-mm-dd' aria-describedby=\"input_20_9_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_20_9_date_format' class='screen-reader-text'>YYYY dash MM dash DD<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_20_9' class='gform_hidden' value='https:\/\/coi.iris.rt5.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_20_116\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_116\"><label class='gfield_label gform-field-label' for='input_20_116' >Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_116' id='input_20_116' type='text' value='' class='datepicker gform-datepicker ymd_dash datepicker_with_icon gdatepicker_with_icon'   placeholder='yyyy-mm-dd' aria-describedby=\"input_20_116_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_20_116_date_format' class='screen-reader-text'>YYYY dash MM dash DD<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_20_116' class='gform_hidden' value='https:\/\/coi.iris.rt5.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_20_8\"  class=\"gfield gfield--type-number gf_middle_third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_8\"><label class='gfield_label gform-field-label' for='input_20_8' >Age<\/label><div class='ginput_container ginput_container_number'><input name='input_8' id='input_20_8' type='text'    value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_20_11\"  class=\"gfield gfield--type-number gf_right_third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_11\"><label class='gfield_label gform-field-label' for='input_20_11' >#chart\/at our clinic<\/label><div class='ginput_container ginput_container_number'><input name='input_11' id='input_20_11' type='text'    value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_20_27\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_27\"><h2 class=\"gsection_title\">Symptoms<\/h2><\/li><li id=\"field_20_13\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_4col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_13\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Distance vision<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_13'><li class='gchoice gchoice_20_13_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.1' type='checkbox'  value='excellent'  id='choice_20_13_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_13_1' id='label_20_13_1' class='gform-field-label gform-field-label--type-inline'>excellent<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_13_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.2' type='checkbox'  value='good'  id='choice_20_13_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_13_2' id='label_20_13_2' class='gform-field-label gform-field-label--type-inline'>good<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_13_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.3' type='checkbox'  value='difficult'  id='choice_20_13_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_13_3' id='label_20_13_3' class='gform-field-label gform-field-label--type-inline'>difficult<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_13_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.4' type='checkbox'  value='unsatisfactory'  id='choice_20_13_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_13_4' id='label_20_13_4' class='gform-field-label gform-field-label--type-inline'>unsatisfactory<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_14\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_4col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_14\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Intermediate<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_14'><li class='gchoice gchoice_20_14_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.1' type='checkbox'  value='excellent'  id='choice_20_14_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_14_1' id='label_20_14_1' class='gform-field-label gform-field-label--type-inline'>excellent<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_14_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.2' type='checkbox'  value='good'  id='choice_20_14_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_14_2' id='label_20_14_2' class='gform-field-label gform-field-label--type-inline'>good<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_14_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.3' type='checkbox'  value='difficult'  id='choice_20_14_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_14_3' id='label_20_14_3' class='gform-field-label gform-field-label--type-inline'>difficult<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_14_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.4' type='checkbox'  value='unsatisfactory'  id='choice_20_14_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_14_4' id='label_20_14_4' class='gform-field-label gform-field-label--type-inline'>unsatisfactory<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_15\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_4col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_15\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Near vision<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_15'><li class='gchoice gchoice_20_15_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.1' type='checkbox'  value='excellent'  id='choice_20_15_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_15_1' id='label_20_15_1' class='gform-field-label gform-field-label--type-inline'>excellent<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_15_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.2' type='checkbox'  value='good'  id='choice_20_15_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_15_2' id='label_20_15_2' class='gform-field-label gform-field-label--type-inline'>good<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_15_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.3' type='checkbox'  value='difficult'  id='choice_20_15_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_15_3' id='label_20_15_3' class='gform-field-label gform-field-label--type-inline'>difficult<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_15_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.4' type='checkbox'  value='unsatisfactory'  id='choice_20_15_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_15_4' id='label_20_15_4' class='gform-field-label gform-field-label--type-inline'>unsatisfactory<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_16\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_4col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_16\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Dryness<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_16'><li class='gchoice gchoice_20_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='absent'  id='choice_20_16_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_16_1' id='label_20_16_1' class='gform-field-label gform-field-label--type-inline'>absent<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='minor'  id='choice_20_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_16_2' id='label_20_16_2' class='gform-field-label gform-field-label--type-inline'>minor<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_16_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.3' type='checkbox'  value='important'  id='choice_20_16_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_16_3' id='label_20_16_3' class='gform-field-label gform-field-label--type-inline'>important<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_16_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.4' type='checkbox'  value='intermittent veil'  id='choice_20_16_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_16_4' id='label_20_16_4' class='gform-field-label gform-field-label--type-inline'>intermittent veil<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_17\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_4col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_17\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Glare<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_17'><li class='gchoice gchoice_20_17_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.1' type='checkbox'  value='absent'  id='choice_20_17_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_17_1' id='label_20_17_1' class='gform-field-label gform-field-label--type-inline'>absent<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_17_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.2' type='checkbox'  value='mineur'  id='choice_20_17_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_17_2' id='label_20_17_2' class='gform-field-label gform-field-label--type-inline'>mineur<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_17_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.3' type='checkbox'  value='mod\u00e9r\u00e9'  id='choice_20_17_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_17_3' id='label_20_17_3' class='gform-field-label gform-field-label--type-inline'>mod\u00e9r\u00e9<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_17_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.4' type='checkbox'  value='g\u00eanant'  id='choice_20_17_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_17_4' id='label_20_17_4' class='gform-field-label gform-field-label--type-inline'>g\u00eanant<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_18\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_4col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_18\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Perception of halos<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_18'><li class='gchoice gchoice_20_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='absent'  id='choice_20_18_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_18_1' id='label_20_18_1' class='gform-field-label gform-field-label--type-inline'>absent<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_18_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.2' type='checkbox'  value='minor'  id='choice_20_18_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_18_2' id='label_20_18_2' class='gform-field-label gform-field-label--type-inline'>minor<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_18_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.3' type='checkbox'  value='moderate'  id='choice_20_18_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_18_3' id='label_20_18_3' class='gform-field-label gform-field-label--type-inline'>moderate<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_18_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.4' type='checkbox'  value='important'  id='choice_20_18_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_18_4' id='label_20_18_4' class='gform-field-label gform-field-label--type-inline'>important<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_19\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_4col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_19\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Pain<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_19'><li class='gchoice gchoice_20_19_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.1' type='checkbox'  value='absent'  id='choice_20_19_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_19_1' id='label_20_19_1' class='gform-field-label gform-field-label--type-inline'>absent<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_19_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.2' type='checkbox'  value='minor'  id='choice_20_19_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_19_2' id='label_20_19_2' class='gform-field-label gform-field-label--type-inline'>minor<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_19_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.3' type='checkbox'  value='moderate'  id='choice_20_19_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_19_3' id='label_20_19_3' class='gform-field-label gform-field-label--type-inline'>moderate<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_19_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.4' type='checkbox'  value='important'  id='choice_20_19_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_19_4' id='label_20_19_4' class='gform-field-label gform-field-label--type-inline'>important<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_20\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_5col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_20\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Perception of flotters<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_20'><li class='gchoice gchoice_20_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='none'  id='choice_20_20_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_20_1' id='label_20_20_1' class='gform-field-label gform-field-label--type-inline'>none<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value='absent'  id='choice_20_20_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_20_2' id='label_20_20_2' class='gform-field-label gform-field-label--type-inline'>absent<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_20_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.3' type='checkbox'  value='minor'  id='choice_20_20_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_20_3' id='label_20_20_3' class='gform-field-label gform-field-label--type-inline'>minor<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_20_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.4' type='checkbox'  value='moderate'  id='choice_20_20_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_20_4' id='label_20_20_4' class='gform-field-label gform-field-label--type-inline'>moderate<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_20_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.5' type='checkbox'  value='important'  id='choice_20_20_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_20_5' id='label_20_20_5' class='gform-field-label gform-field-label--type-inline'>important<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_21\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_21\"><label class='gfield_label gform-field-label' for='input_20_21' >Additional comments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_21' id='input_20_21' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_20_28\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_28\"><h2 class=\"gsection_title\">Surgery<\/h2><\/li><li id=\"field_20_23\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_4col gf_left_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_23\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Delay since surgery - OD<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_23'><li class='gchoice gchoice_20_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='1 week'  id='choice_20_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_23_1' id='label_20_23_1' class='gform-field-label gform-field-label--type-inline'>1 week<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='1 month'  id='choice_20_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_23_2' id='label_20_23_2' class='gform-field-label gform-field-label--type-inline'>1 month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_23_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.3' type='checkbox'  value='3 month'  id='choice_20_23_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_23_3' id='label_20_23_3' class='gform-field-label gform-field-label--type-inline'>3 month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_23_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.4' type='checkbox'  value='other'  id='choice_20_23_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_23_4' id='label_20_23_4' class='gform-field-label gform-field-label--type-inline'>other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_24\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_4col gf_right_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_24\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Delay since surgery - OS<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_24'><li class='gchoice gchoice_20_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='1 week'  id='choice_20_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_24_1' id='label_20_24_1' class='gform-field-label gform-field-label--type-inline'>1 week<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='1 month'  id='choice_20_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_24_2' id='label_20_24_2' class='gform-field-label gform-field-label--type-inline'>1 month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_24_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.3' type='checkbox'  value='3 month'  id='choice_20_24_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_24_3' id='label_20_24_3' class='gform-field-label gform-field-label--type-inline'>3 month<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_24_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.4' type='checkbox'  value='other'  id='choice_20_24_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_24_4' id='label_20_24_4' class='gform-field-label gform-field-label--type-inline'>other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_29\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_4col gf_left_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_29\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Type of IOL - OD<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_29'><li class='gchoice gchoice_20_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.1' type='checkbox'  value='mono'  id='choice_20_29_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_29_1' id='label_20_29_1' class='gform-field-label gform-field-label--type-inline'>mono<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_29_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.2' type='checkbox'  value='multifocal'  id='choice_20_29_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_29_2' id='label_20_29_2' class='gform-field-label gform-field-label--type-inline'>multifocal<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_29_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.3' type='checkbox'  value='toric'  id='choice_20_29_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_29_3' id='label_20_29_3' class='gform-field-label gform-field-label--type-inline'>toric<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_30\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_3col gf_right_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_30\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Type of IOL - OS<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_30'><li class='gchoice gchoice_20_30_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.1' type='checkbox'  value='mono'  id='choice_20_30_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_30_1' id='label_20_30_1' class='gform-field-label gform-field-label--type-inline'>mono<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_30_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.2' type='checkbox'  value='multifocal'  id='choice_20_30_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_30_2' id='label_20_30_2' class='gform-field-label gform-field-label--type-inline'>multifocal<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_30_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.3' type='checkbox'  value='toric'  id='choice_20_30_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_30_3' id='label_20_30_3' class='gform-field-label gform-field-label--type-inline'>toric<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_40\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_left_half gf_list_4col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_40\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Targeted correction - OD<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_40'><li class='gchoice gchoice_20_40_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.1' type='checkbox'  value='DV'  id='choice_20_40_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_40_1' id='label_20_40_1' class='gform-field-label gform-field-label--type-inline'>DV<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_40_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.2' type='checkbox'  value='IV'  id='choice_20_40_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_40_2' id='label_20_40_2' class='gform-field-label gform-field-label--type-inline'>IV<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_40_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.3' type='checkbox'  value='NV'  id='choice_20_40_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_40_3' id='label_20_40_3' class='gform-field-label gform-field-label--type-inline'>NV<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_40_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.4' type='checkbox'  value='other'  id='choice_20_40_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_40_4' id='label_20_40_4' class='gform-field-label gform-field-label--type-inline'>other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_41\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_right_half gf_list_4col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_41\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Targeted correction - OS<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_41'><li class='gchoice gchoice_20_41_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.1' type='checkbox'  value='DV'  id='choice_20_41_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_41_1' id='label_20_41_1' class='gform-field-label gform-field-label--type-inline'>DV<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_41_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.2' type='checkbox'  value='IV'  id='choice_20_41_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_41_2' id='label_20_41_2' class='gform-field-label gform-field-label--type-inline'>IV<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_41_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.3' type='checkbox'  value='NV'  id='choice_20_41_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_41_3' id='label_20_41_3' class='gform-field-label gform-field-label--type-inline'>NV<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_41_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.4' type='checkbox'  value='other'  id='choice_20_41_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_41_4' id='label_20_41_4' class='gform-field-label gform-field-label--type-inline'>other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_125\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_125\"><h2 class=\"gsection_title\">UCVA DV<\/h2><\/li><li id=\"field_20_117\"  class=\"gfield gfield--type-html gf_first_quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_117\"><div><strong>UCVA DV - OU<\/strong><\/div><\/li><li id=\"field_20_119\"  class=\"gfield gfield--type-text gf_second_quarter six_slash field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_20_119\"><label class='gfield_label gform-field-label' for='input_20_119' >6\/<\/label><div class='ginput_container ginput_container_text'><input name='input_119' id='input_20_119' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_120\"  class=\"gfield gfield--type-html gf_third_quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_120\"><\/li><li id=\"field_20_118\"  class=\"gfield gfield--type-html gf_fourth_quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_118\"><\/li><li id=\"field_20_84\"  class=\"gfield gfield--type-html gf_left_half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_84\"><div><strong>UCVA DV  - OD<\/strong><\/div><\/li><li id=\"field_20_87\"  class=\"gfield gfield--type-html gf_right_half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_87\"><div><strong>UCVA DV  - OS<\/strong><\/div><\/li><li id=\"field_20_85\"  class=\"gfield gfield--type-text gf_first_quarter six_slash field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_20_85\"><label class='gfield_label gform-field-label' for='input_20_85' >6\/<\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_20_85' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_86\"  class=\"gfield gfield--type-text gf_second_quarter ts_six_slash field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_20_86\"><label class='gfield_label gform-field-label' for='input_20_86' >TS 6\/<\/label><div class='ginput_container ginput_container_text'><input name='input_86' id='input_20_86' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_88\"  class=\"gfield gfield--type-text gf_third_quarter six_slash field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_20_88\"><label class='gfield_label gform-field-label' for='input_20_88' >6\/<\/label><div class='ginput_container ginput_container_text'><input name='input_88' id='input_20_88' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_89\"  class=\"gfield gfield--type-text gf_fourth_quarter ts_six_slash field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_20_89\"><label class='gfield_label gform-field-label' for='input_20_89' >TS 6\/<\/label><div class='ginput_container ginput_container_text'><input name='input_89' id='input_20_89' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_126\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_126\"><h2 class=\"gsection_title\">UCVA NV<\/h2><\/li><li id=\"field_20_121\"  class=\"gfield gfield--type-html gf_first_quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_121\"><div><strong>UCVA NV  - OU<\/strong><\/div><\/li><li id=\"field_20_123\"  class=\"gfield gfield--type-text gf_second_quarter six_slash_m field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_20_123\"><label class='gfield_label gform-field-label' for='input_20_123' >M<\/label><div class='ginput_container ginput_container_text'><input name='input_123' id='input_20_123' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_124\"  class=\"gfield gfield--type-text gf_third_quarter six_slash_a_cm field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_20_124\"><label class='gfield_label gform-field-label' for='input_20_124' >at cm<\/label><div class='ginput_container ginput_container_text'><input name='input_124' id='input_20_124' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_122\"  class=\"gfield gfield--type-html gf_fourth_quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_122\"><\/li><li id=\"field_20_90\"  class=\"gfield gfield--type-html gf_left_half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_90\"><div><strong>UCVA NV  - OD<\/strong><\/div><\/li><li id=\"field_20_91\"  class=\"gfield gfield--type-html gf_right_half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_91\"><div><strong>UCVA NV  - OS<\/strong><\/div><\/li><li id=\"field_20_92\"  class=\"gfield gfield--type-text gf_first_quarter six_slash_m field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_20_92\"><label class='gfield_label gform-field-label' for='input_20_92' >M<\/label><div class='ginput_container ginput_container_text'><input name='input_92' id='input_20_92' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_93\"  class=\"gfield gfield--type-text gf_second_quarter six_slash_a_cm field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_20_93\"><label class='gfield_label gform-field-label' for='input_20_93' >at cm<\/label><div class='ginput_container ginput_container_text'><input name='input_93' id='input_20_93' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_94\"  class=\"gfield gfield--type-text gf_third_quarter six_slash_m field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_20_94\"><label class='gfield_label gform-field-label' for='input_20_94' >M<\/label><div class='ginput_container ginput_container_text'><input name='input_94' id='input_20_94' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_95\"  class=\"gfield gfield--type-text gf_fourth_quarter six_slash_a_cm field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_20_95\"><label class='gfield_label gform-field-label' for='input_20_95' >at cm<\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_20_95' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_131\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_131\"><h2 class=\"gsection_title\">Refraction<\/h2><\/li><li id=\"field_20_96\"  class=\"gfield gfield--type-html gf_left_half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_96\"><div><strong>Subjective refraction - OD<\/strong><\/div><\/li><li id=\"field_20_99\"  class=\"gfield gfield--type-html gf_left_half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_99\"><div><strong>Subjective refraction - OS<\/strong><\/div><\/li><li id=\"field_20_97\"  class=\"gfield gfield--type-text gf_first_quarter input_5t field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_20_97\"><label class='gfield_label gform-field-label' for='input_20_97' >R\u00e9fraction subjective - OD<\/label><div class='ginput_container ginput_container_text'><input name='input_97' id='input_20_97' type='text' value='' class='medium'    placeholder='0.00'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_98\"  class=\"gfield gfield--type-text gf_second_quarter six_slash field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_20_98\"><label class='gfield_label gform-field-label' for='input_20_98' >r\u00e9fraction subjective - od 6\/<\/label><div class='ginput_container ginput_container_text'><input name='input_98' id='input_20_98' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_100\"  class=\"gfield gfield--type-text gf_third_quarter input_5t field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_20_100\"><label class='gfield_label gform-field-label' for='input_20_100' >R\u00e9fraction subjective - OS<\/label><div class='ginput_container ginput_container_text'><input name='input_100' id='input_20_100' type='text' value='' class='medium'    placeholder='0.00'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_101\"  class=\"gfield gfield--type-text gf_fourth_quarter six_slash field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_20_101\"><label class='gfield_label gform-field-label' for='input_20_101' >r\u00e9fraction subjective - os 6\/<\/label><div class='ginput_container ginput_container_text'><input name='input_101' id='input_20_101' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_102\"  class=\"gfield gfield--type-html gf_left_half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_102\"><div><strong>Electronic refraction - OD<\/strong><\/div><\/li><li id=\"field_20_103\"  class=\"gfield gfield--type-html gf_left_half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_103\"><div><strong>Electronic refraction - OS<\/strong><\/div><\/li><li id=\"field_20_104\"  class=\"gfield gfield--type-text gf_first_quarter input_5t field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_20_104\"><label class='gfield_label gform-field-label' for='input_20_104' >R\u00e9fraction subjective - OD<\/label><div class='ginput_container ginput_container_text'><input name='input_104' id='input_20_104' type='text' value='' class='medium'    placeholder='0.00'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_105\"  class=\"gfield gfield--type-text gf_second_quarter six_slash field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_20_105\"><label class='gfield_label gform-field-label' for='input_20_105' >r\u00e9fraction subjective - od 6\/<\/label><div class='ginput_container ginput_container_text'><input name='input_105' id='input_20_105' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_106\"  class=\"gfield gfield--type-text gf_third_quarter input_5t field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_20_106\"><label class='gfield_label gform-field-label' for='input_20_106' >R\u00e9fraction subjective - OS<\/label><div class='ginput_container ginput_container_text'><input name='input_106' id='input_20_106' type='text' value='' class='medium'    placeholder='0.00'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_107\"  class=\"gfield gfield--type-text gf_fourth_quarter six_slash field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_20_107\"><label class='gfield_label gform-field-label' for='input_20_107' >r\u00e9fraction subjective - os 6\/<\/label><div class='ginput_container ginput_container_text'><input name='input_107' id='input_20_107' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_108\"  class=\"gfield gfield--type-time gf_left_third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_108\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Intraocular pressure<\/label><div class=\"ginput_container ginput_complex gform-grid-row\"><div class=\"clear-multi\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_20_108'>\n                            <input type='text' maxlength='2' name='input_108[]' id='input_20_108_1' value=''    placeholder='HH' aria-required='false'   \/> <i>:<\/i>\n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_20_108_1'>Hours<\/label>\n                        <\/div>\n                        \n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='text' maxlength='2' name='input_108[]' id='input_20_108_2' value=''    placeholder='MM' aria-required='false'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_20_108_2'>Minutes<\/label>\n                        <\/div>\n                        \n                    <\/div><\/div><\/li><li id=\"field_20_111\"  class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gf_list_2col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_111\"><label class='gfield_label gform-field-label'  >Method<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_20_111'>\n\t\t\t<li class='gchoice gchoice_20_111_0'>\n\t\t\t\t<input name='input_111' type='radio' value='NCT (Air blast)'  id='choice_20_111_0'    \/>\n\t\t\t\t<label for='choice_20_111_0' id='label_20_111_0' class='gform-field-label gform-field-label--type-inline'>NCT (Air blast)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_20_111_1'>\n\t\t\t\t<input name='input_111' type='radio' value='Goldmann (applanation)'  id='choice_20_111_1'    \/>\n\t\t\t\t<label for='choice_20_111_1' id='label_20_111_1' class='gform-field-label gform-field-label--type-inline'>Goldmann (applanation)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_109\"  class=\"gfield gfield--type-text gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_109\"><label class='gfield_label gform-field-label' for='input_20_109' >IOP - OD<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_109' id='input_20_109' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_110\"  class=\"gfield gfield--type-text gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_110\"><label class='gfield_label gform-field-label' for='input_20_110' >IOP - OS<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_110' id='input_20_110' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_1\"  class=\"gfield gfield--type-signature gf_third_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_1\"><label class='gfield_label gform-field-label' for='input_20_1' >Left eye<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_20_1_Container' class='gfield_signature_container ginput_container' style='height:180px; width:180px; ' ><input type='hidden' class='gform_hidden' name='input_20_1_valid' id='input_20_1_valid' \/><canvas id='input_20_1' width='180' height='180'><\/canvas><\/div><\/div><\/li><li id=\"field_20_3\"  class=\"gfield gfield--type-signature gf_fourth_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_3\"><label class='gfield_label gform-field-label' for='input_20_3' >Right eye<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_20_3_Container' class='gfield_signature_container ginput_container' style='height:180px; width:180px; ' ><input type='hidden' class='gform_hidden' name='input_20_3_valid' id='input_20_3_valid' \/><canvas id='input_20_3' width='180' height='180'><\/canvas><\/div><\/div><\/li><li id=\"field_20_129\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_129\"><h2 class=\"gsection_title\">Grades<\/h2><\/li><li id=\"field_20_130\"  class=\"gfield gfield--type-html gf_list_5col gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_130\"><div style=\"text-align: center;\"><strong>1\/2: trace&nbsp;&nbsp;&nbsp;1: minor&nbsp;&nbsp;&nbsp2: moderate&nbsp;&nbsp;&nbsp;3: moderately significant&nbsp;&nbsp;&nbsp;4: severe<\/strong><\/div><\/li><li id=\"field_20_43\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_check_input gf_one_quarter first field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_43\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Hyperemia - OD<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_43'><li class='gchoice gchoice_20_43_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.1' type='checkbox'  value='none'  id='choice_20_43_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_43_1' id='label_20_43_1' class='gform-field-label gform-field-label--type-inline'>none<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_43_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.2' type='checkbox'  value='present'  id='choice_20_43_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_43_2' id='label_20_43_2' class='gform-field-label gform-field-label--type-inline'>present<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_44\"  class=\"gfield gfield--type-text gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_44\"><label class='gfield_label gform-field-label' for='input_20_44' >&nbsp;<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_20_44' type='text' value='' class='large'    placeholder='grade'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_45\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_check_input gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_45\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Hyperemia - OS<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_45'><li class='gchoice gchoice_20_45_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.1' type='checkbox'  value='none'  id='choice_20_45_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_45_1' id='label_20_45_1' class='gform-field-label gform-field-label--type-inline'>none<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_45_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.2' type='checkbox'  value='present'  id='choice_20_45_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_45_2' id='label_20_45_2' class='gform-field-label gform-field-label--type-inline'>present<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_46\"  class=\"gfield gfield--type-text gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_46\"><label class='gfield_label gform-field-label' for='input_20_46' >&nbsp;<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_20_46' type='text' value='' class='large'    placeholder='grade'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_47\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_check_input gf_one_quarter first field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_47\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Edema Conj\/Lid - OD<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_47'><li class='gchoice gchoice_20_47_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.1' type='checkbox'  value='none'  id='choice_20_47_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_47_1' id='label_20_47_1' class='gform-field-label gform-field-label--type-inline'>none<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_47_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.2' type='checkbox'  value='present'  id='choice_20_47_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_47_2' id='label_20_47_2' class='gform-field-label gform-field-label--type-inline'>present<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_48\"  class=\"gfield gfield--type-text gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_48\"><label class='gfield_label gform-field-label' for='input_20_48' >&nbsp;<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_20_48' type='text' value='' class='large'    placeholder='grade'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_49\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_check_input gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_49\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Edema Conj\/Lid - OS<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_49'><li class='gchoice gchoice_20_49_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.1' type='checkbox'  value='none'  id='choice_20_49_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_49_1' id='label_20_49_1' class='gform-field-label gform-field-label--type-inline'>none<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_49_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.2' type='checkbox'  value='present'  id='choice_20_49_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_49_2' id='label_20_49_2' class='gform-field-label gform-field-label--type-inline'>present<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_50\"  class=\"gfield gfield--type-text gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_50\"><label class='gfield_label gform-field-label' for='input_20_50' >&nbsp;<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_20_50' type='text' value='' class='large'    placeholder='grade'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_51\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_check_input gf_one_quarter first field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_51\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Incision - OD<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_51'><li class='gchoice gchoice_20_51_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.1' type='checkbox'  value='sealed'  id='choice_20_51_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_51_1' id='label_20_51_1' class='gform-field-label gform-field-label--type-inline'>sealed<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_51_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.2' type='checkbox'  value='leak'  id='choice_20_51_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_51_2' id='label_20_51_2' class='gform-field-label gform-field-label--type-inline'>leak<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_127\"  class=\"gfield gfield--type-html gf_one_quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_127\"><\/li><li id=\"field_20_53\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_check_input gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_53\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Incision - OS<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_53'><li class='gchoice gchoice_20_53_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.1' type='checkbox'  value='sealed'  id='choice_20_53_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_53_1' id='label_20_53_1' class='gform-field-label gform-field-label--type-inline'>sealed<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_53_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.2' type='checkbox'  value='leak'  id='choice_20_53_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_53_2' id='label_20_53_2' class='gform-field-label gform-field-label--type-inline'>leak<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_128\"  class=\"gfield gfield--type-html gf_one_quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_128\"><\/li><li id=\"field_20_36\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_check_input gf_one_quarter first field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_36\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Cornea - OD<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_36'><li class='gchoice gchoice_20_36_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.1' type='checkbox'  value='clear'  id='choice_20_36_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_36_1' id='label_20_36_1' class='gform-field-label gform-field-label--type-inline'>clear<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_36_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.2' type='checkbox'  value='edema'  id='choice_20_36_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_36_2' id='label_20_36_2' class='gform-field-label gform-field-label--type-inline'>edema<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_37\"  class=\"gfield gfield--type-text gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_37\"><label class='gfield_label gform-field-label' for='input_20_37' >&nbsp;<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_20_37' type='text' value='' class='large'    placeholder='grade'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_38\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_check_input gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_38\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Cornea - OS<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_38'><li class='gchoice gchoice_20_38_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.1' type='checkbox'  value='clear'  id='choice_20_38_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_38_1' id='label_20_38_1' class='gform-field-label gform-field-label--type-inline'>clear<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_38_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.2' type='checkbox'  value='edema'  id='choice_20_38_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_38_2' id='label_20_38_2' class='gform-field-label gform-field-label--type-inline'>edema<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_39\"  class=\"gfield gfield--type-text gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_39\"><label class='gfield_label gform-field-label' for='input_20_39' >&nbsp;<\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_20_39' type='text' value='' class='large'    placeholder='grade'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_55\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_check_input gf_one_quarter first field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_55\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Anterior chamber - OD<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_55'><li class='gchoice gchoice_20_55_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.1' type='checkbox'  value='quiet'  id='choice_20_55_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_55_1' id='label_20_55_1' class='gform-field-label gform-field-label--type-inline'>quiet<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_55_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.2' type='checkbox'  value='cell\/flare'  id='choice_20_55_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_55_2' id='label_20_55_2' class='gform-field-label gform-field-label--type-inline'>cell\/flare<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_56\"  class=\"gfield gfield--type-text gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_56\"><label class='gfield_label gform-field-label' for='input_20_56' >&nbsp;<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_20_56' type='text' value='' class='large'    placeholder='grade'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_57\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_check_input gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_57\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Anterior chamber - OS<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_57'><li class='gchoice gchoice_20_57_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.1' type='checkbox'  value='quiet'  id='choice_20_57_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_57_1' id='label_20_57_1' class='gform-field-label gform-field-label--type-inline'>quiet<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_57_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.2' type='checkbox'  value='cell\/flare'  id='choice_20_57_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_57_2' id='label_20_57_2' class='gform-field-label gform-field-label--type-inline'>cell\/flare<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_58\"  class=\"gfield gfield--type-text gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_58\"><label class='gfield_label gform-field-label' for='input_20_58' >&nbsp;<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_20_58' type='text' value='' class='large'    placeholder='grade'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_60\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_check_input gf_one_quarter vertical first field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_60\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Posterior capsule - OD<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_60'><li class='gchoice gchoice_20_60_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.1' type='checkbox'  value='clean'  id='choice_20_60_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_60_1' id='label_20_60_1' class='gform-field-label gform-field-label--type-inline'>clean<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_60_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.2' type='checkbox'  value='opacity'  id='choice_20_60_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_60_2' id='label_20_60_2' class='gform-field-label gform-field-label--type-inline'>opacity<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_60_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.3' type='checkbox'  value='folds'  id='choice_20_60_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_60_3' id='label_20_60_3' class='gform-field-label gform-field-label--type-inline'>folds<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_61\"  class=\"gfield gfield--type-text gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_61\"><label class='gfield_label gform-field-label' for='input_20_61' >&nbsp;<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_20_61' type='text' value='' class='large'    placeholder='grade'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_62\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_check_input gf_one_quarter vertical field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_62\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Posterior capsule - OS<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_62'><li class='gchoice gchoice_20_62_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.1' type='checkbox'  value='clean'  id='choice_20_62_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_62_1' id='label_20_62_1' class='gform-field-label gform-field-label--type-inline'>clean<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_62_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.2' type='checkbox'  value='opacity'  id='choice_20_62_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_62_2' id='label_20_62_2' class='gform-field-label gform-field-label--type-inline'>opacity<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_62_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.3' type='checkbox'  value='folds'  id='choice_20_62_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_62_3' id='label_20_62_3' class='gform-field-label gform-field-label--type-inline'>folds<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_63\"  class=\"gfield gfield--type-text gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_63\"><label class='gfield_label gform-field-label' for='input_20_63' >&nbsp;<\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_20_63' type='text' value='' class='large'    placeholder='grade'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_65\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_check_input gf_one_quarter first field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_65\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Macula - OD<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_65'><li class='gchoice gchoice_20_65_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.1' type='checkbox'  value='Sane'  id='choice_20_65_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_65_1' id='label_20_65_1' class='gform-field-label gform-field-label--type-inline'>Sane<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_65_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.2' type='checkbox'  value='Omk'  id='choice_20_65_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_65_2' id='label_20_65_2' class='gform-field-label gform-field-label--type-inline'>Omk<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_66\"  class=\"gfield gfield--type-text gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_66\"><label class='gfield_label gform-field-label' for='input_20_66' >&nbsp;<\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_20_66' type='text' value='' class='large'    placeholder='grade'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_67\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_check_input gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_67\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Macula - OS<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_67'><li class='gchoice gchoice_20_67_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.1' type='checkbox'  value='Sane'  id='choice_20_67_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_67_1' id='label_20_67_1' class='gform-field-label gform-field-label--type-inline'>Sane<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_67_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.2' type='checkbox'  value='Omk'  id='choice_20_67_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_67_2' id='label_20_67_2' class='gform-field-label gform-field-label--type-inline'>Omk<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_68\"  class=\"gfield gfield--type-text gf_one_quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_68\"><label class='gfield_label gform-field-label' for='input_20_68' >&nbsp;<\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_20_68' type='text' value='' class='large'    placeholder='grade'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_73\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_73\"><br\/><\/li><li id=\"field_20_72\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_72\"><label class='gfield_label gform-field-label' for='input_20_72' >Recommandations<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_72' id='input_20_72' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_20_115\"  class=\"gfield gfield--type-text gf_list_2col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_115\"><label class='gfield_label gform-field-label' for='input_20_115' >Next appointment<\/label><div class='ginput_container ginput_container_text'><input name='input_115' id='input_20_115' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_74\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_2col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_74\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Communication<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_20_74'><li class='gchoice gchoice_20_74_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.1' type='checkbox'  value='I have additional information for this patient and I would like you to contact me'  id='choice_20_74_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_74_1' id='label_20_74_1' class='gform-field-label gform-field-label--type-inline'>I have additional information for this patient and I would like you to contact me<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_20_74_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.2' type='checkbox'  value='Urgent'  id='choice_20_74_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_74_2' id='label_20_74_2' class='gform-field-label gform-field-label--type-inline'>Urgent<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_20_76\"  class=\"gfield gfield--type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_20_76\"><label class='gfield_label gform-field-label' for='input_20_76' >Optometrist<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_76' id='input_20_76' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_20_77\"  class=\"gfield gfield--type-text gf_right_half no_membre_label gfield_contains_required field_sublabel_below 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