{"id":1086,"date":"2022-06-08T09:47:11","date_gmt":"2022-06-08T07:47:11","guid":{"rendered":"https:\/\/plateforme.hopital-foch.com\/?page_id=1086"},"modified":"2022-12-02T13:52:14","modified_gmt":"2022-12-02T12:52:14","slug":"questionnaire-douleur","status":"publish","type":"page","link":"https:\/\/plateforme.hopital-foch.com\/fr\/questionnaire-douleur\/","title":{"rendered":"Questionnaire douleur"},"content":{"rendered":"\n<p><\/p>\n\n\n\n<p>Madame, Monsieur,<br>Vous souhaitez b\u00e9n\u00e9ficier d\u2019un rendez-vous en consultation douleur au niveau de notre&nbsp;CETD.<\/p>\n\n\n\n<p>Pour nous permettre de r\u00e9pondre au mieux \u00e0 votre demande, nous vous invitons \u00e0 <strong>compl\u00e9ter le document ci-joint qui comprend une partie \u00e0 faire remplir par votre m\u00e9decin r\u00e9f\u00e9rent.<\/strong><br>Ce document doit \u00eatre adress\u00e9 au secr\u00e9tariat du&nbsp; CETD par voie postale<\/p>\n\n\n\n<p><strong>Institut Line Renaud<\/strong><br><strong>28 avenue Charles de Gaulle<\/strong><br><strong>92150 SURESNES<\/strong><\/p>\n\n\n\n<p>ou par&nbsp;mail<\/p>\n\n\n\n<p><a href=\"mailto:secretariat.clud@hopital-foch.com\" target=\"_blank\" rel=\"noreferrer noopener\"><strong>secretariat.clud@hopital-foch.com<\/strong><\/a><\/p>\n\n\n\n<p>Les d\u00e9lais pour une premi\u00e8re consultation dans notre centre varient actuellement entre 4 \u00e0 6 mois. Les demandes sont trait\u00e9es en fonction du degr\u00e9 d\u2019urgence \u00e9valu\u00e9 par les m\u00e9decins du service.<br>Votre RDV sera programm\u00e9 dans les meilleurs d\u00e9lais et une convocation vous sera transmise avec la date et l\u2019heure de votre&nbsp;RDV&nbsp;;<\/p>\n\n\n\n<p><strong>En cas d\u2019impr\u00e9vus merci de nous pr\u00e9venir au <a href=\"tel:\/\/+33146252426\">01 46 25 24 26<\/a> entre 10h et 12h ou par<\/strong><br><strong>mail<\/strong>&nbsp;: <a href=\"mailto:secretariat.clud@hopital-foch.com\" target=\"_blank\" rel=\"noreferrer noopener\">secretariat.clud@hopital-foch.com<\/a><\/p>\n\n\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 gravity-theme gform-theme--no-framework\" data-form-theme=\"gravity-theme\" data-form-index=\"0\" id=\"gform_wrapper_19\" style=\"display:none\"><div id=\"gf_19\" class=\"gform_anchor\" tabindex=\"-1\"><\/div>\n                        <div class=\"gform_heading\">\n                            <h2 class=\"gform_title\">Centre d\u2019\u00e9tude et traitement de la douleur<\/h2>\n                        <\/div><form method=\"post\" enctype=\"multipart\/form-data\" id=\"gform_19\" action=\"\/fr\/wp-json\/wp\/v2\/pages\/1086#gf_19\" data-formid=\"19\" novalidate>\n        <div id=\"gf_progressbar_wrapper_19\" class=\"gf_progressbar_wrapper\">\n        \t<p class=\"gf_progressbar_title\">\u00c9tape <span class=\"gf_step_current_page\">1<\/span> sur <span class=\"gf_step_page_count\">3<\/span>\n        \t<\/p>\n            <div class=\"gf_progressbar gf_progressbar_blue\" aria-hidden=\"true\">\n                <div class=\"gf_progressbar_percentage percentbar_blue percentbar_33\" style=\"width:33%;\"><span>33%<\/span><\/div>\n            <\/div><\/div>\n                        <div class=\"gform-body gform_body\"><div id=\"gform_page_19_1\" class=\"gform_page \" data-js=\"page-field-id-1\">\n                                    <div class=\"gform_page_fields\"><div id=\"gform_fields_19\" class=\"gform_fields top_label form_sublabel_below description_below\"><div id=\"field_19_37\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_37\"><h3 class=\"gsection_title\">PARTIE \u00c0 REMPLIR PAR LE PATIENT<\/h3><\/div><div id=\"field_19_1\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_1\"><label class=\"gfield_label gform-field-label\" for=\"input_19_1\">Date de la demande<\/label><div class=\"ginput_container ginput_container_date\">\n                            <input name=\"input_1\" id=\"input_19_1\" type=\"text\" value class=\"datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon\" placeholder=\"jj\/mm\/aaaa\" aria-describedby=\"input_19_1_date_format\" aria-invalid=\"false\">\n                            <span id=\"input_19_1_date_format\" class=\"screen-reader-text\">JJ slash MM slash&nbsp;AAAA<\/span>\n                        <\/div>\n                        <input type=\"hidden\" id=\"gforms_calendar_icon_input_19_1\" class=\"gform_hidden\" value=\"https:\/\/plateforme.hopital-foch.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg\"><\/div><div id=\"field_19_2\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_2\"><h3 class=\"gsection_title\">Vos coordonn\u00e9es<\/h3><\/div><div id=\"field_19_3\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_3\"><label class=\"gfield_label gform-field-label\" for=\"input_19_3\">Nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class=\"ginput_container ginput_container_text\"><input name=\"input_3\" id=\"input_19_3\" type=\"text\" value class=\"large\" aria-required=\"true\" aria-invalid=\"false\"> <\/div><\/div><div id=\"field_19_4\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_4\"><label class=\"gfield_label gform-field-label\" for=\"input_19_4\">Pr\u00e9nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class=\"ginput_container ginput_container_text\"><input name=\"input_4\" id=\"input_19_4\" type=\"text\" value class=\"large\" aria-required=\"true\" aria-invalid=\"false\"> <\/div><\/div><div id=\"field_19_5\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_5\"><label class=\"gfield_label gform-field-label\" for=\"input_19_5\">Date de naissance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class=\"ginput_container ginput_container_date\">\n                            <input name=\"input_5\" id=\"input_19_5\" type=\"text\" value class=\"datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon\" placeholder=\"mm\/jj\/aaaa\" aria-describedby=\"input_19_5_date_format\" aria-invalid=\"false\" aria-required=\"true\">\n                            <span id=\"input_19_5_date_format\" class=\"screen-reader-text\">MM slash JJ slash&nbsp;AAAA<\/span>\n                        <\/div>\n                        <input type=\"hidden\" id=\"gforms_calendar_icon_input_19_5\" class=\"gform_hidden\" value=\"https:\/\/plateforme.hopital-foch.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg\"><\/div><div id=\"field_19_6\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_6\"><label class=\"gfield_label gform-field-label\" for=\"input_19_6\">\u00c2ge<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class=\"ginput_container ginput_container_text\"><input name=\"input_6\" id=\"input_19_6\" type=\"text\" value class=\"large\" aria-required=\"true\" aria-invalid=\"false\"> <\/div><\/div><div id=\"field_19_7\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_7\"><label class=\"gfield_label gform-field-label\" for=\"input_19_7\">Adresse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class=\"ginput_container ginput_container_text\"><input name=\"input_7\" id=\"input_19_7\" type=\"text\" value class=\"large\" aria-required=\"true\" aria-invalid=\"false\"> <\/div><\/div><div id=\"field_19_8\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_8\"><label class=\"gfield_label gform-field-label\" for=\"input_19_8\">T\u00e9l\u00e9phone(s)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class=\"ginput_container ginput_container_text\"><input name=\"input_8\" id=\"input_19_8\" type=\"text\" value class=\"large\" aria-required=\"true\" aria-invalid=\"false\"> <\/div><\/div><div id=\"field_19_9\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_9\"><label class=\"gfield_label gform-field-label\" for=\"input_19_9\">Portable<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class=\"ginput_container ginput_container_text\"><input name=\"input_9\" id=\"input_19_9\" type=\"text\" value class=\"large\" aria-required=\"true\" aria-invalid=\"false\"> <\/div><\/div><div id=\"field_19_11\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_11\"><label class=\"gfield_label gform-field-label\" for=\"input_19_11\">E\u2011mail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class=\"ginput_container ginput_container_email\">\n                            <input name=\"input_11\" id=\"input_19_11\" type=\"email\" value class=\"large\" aria-required=\"true\" aria-invalid=\"false\">\n                        <\/div><\/div><div id=\"field_19_12\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_12\"><h3 class=\"gsection_title\">M\u00e9decin traitant d\u00e9clar\u00e9 \u00e0 la caisse primaire d\u2019assurance maladie (nom et adresse)<\/h3><\/div><div id=\"field_19_13\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_13\"><label class=\"gfield_label gform-field-label\" for=\"input_19_13\">Motif de consultation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class=\"ginput_container ginput_container_textarea\"><textarea name=\"input_13\" id=\"input_19_13\" class=\"textarea large\" aria-required=\"true\" aria-invalid=\"false\" rows=\"10\" cols=\"50\"><\/textarea><\/div><\/div><div id=\"field_19_15\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_15\"><h3 class=\"gsection_title\">Votre situation professionnelle actuelle<\/h3><\/div><div id=\"field_19_16\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_16\"><label class=\"gfield_label gform-field-label\" for=\"input_19_16\">Profession<\/label><div class=\"ginput_container ginput_container_text\"><input name=\"input_16\" id=\"input_19_16\" type=\"text\" value class=\"large\" aria-invalid=\"false\"> <\/div><\/div><fieldset id=\"field_19_17\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_2col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_17\"><legend class=\"gfield_label gform-field-label\">Arr\u00eat de travail en lien avec la douleur<\/legend><div class=\"ginput_container ginput_container_radio\"><div class=\"gfield_radio\" id=\"input_19_17\">\n\t\t\t<div class=\"gchoice gchoice_19_17_0\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_17\" type=\"radio\" value=\"Oui\" id=\"choice_19_17_0\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_17_0\" id=\"label_19_17_0\" class=\"gform-field-label gform-field-label--type-inline\">Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_17_1\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_17\" type=\"radio\" value=\"Non\" id=\"choice_19_17_1\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_17_1\" id=\"label_19_17_1\" class=\"gform-field-label gform-field-label--type-inline\">Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_19_19\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_19\"><label class=\"gfield_label gform-field-label\" for=\"input_19_19\">Depuis quand&nbsp;?<\/label><div class=\"ginput_container ginput_container_date\">\n                            <input name=\"input_19\" id=\"input_19_19\" type=\"text\" value class=\"datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon\" placeholder=\"mm\/jj\/aaaa\" aria-describedby=\"input_19_19_date_format\" aria-invalid=\"false\">\n                            <span id=\"input_19_19_date_format\" class=\"screen-reader-text\">MM slash JJ slash&nbsp;AAAA<\/span>\n                        <\/div>\n                        <input type=\"hidden\" id=\"gforms_calendar_icon_input_19_19\" class=\"gform_hidden\" value=\"https:\/\/plateforme.hopital-foch.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg\"><\/div><fieldset id=\"field_19_20\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_20\"><legend class=\"gfield_label gform-field-label\">Votre douleur est-elle en lien avec un accident de travail&nbsp;?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class=\"ginput_container ginput_container_radio\"><div class=\"gfield_radio\" id=\"input_19_20\">\n\t\t\t<div class=\"gchoice gchoice_19_20_0\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_20\" type=\"radio\" value=\"Oui\" id=\"choice_19_20_0\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_20_0\" id=\"label_19_20_0\" class=\"gform-field-label gform-field-label--type-inline\">Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_20_1\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_20\" type=\"radio\" value=\"Non\" id=\"choice_19_20_1\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_20_1\" id=\"label_19_20_1\" class=\"gform-field-label gform-field-label--type-inline\">Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_19_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_21\"><legend class=\"gfield_label gform-field-label\">Votre douleur entre-t-elle dans le cadre d\u2019une maladie professionnelle&nbsp;?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class=\"ginput_container ginput_container_radio\"><div class=\"gfield_radio\" id=\"input_19_21\">\n\t\t\t<div class=\"gchoice gchoice_19_21_0\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_21\" type=\"radio\" value=\"Oui\" id=\"choice_19_21_0\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_21_0\" id=\"label_19_21_0\" class=\"gform-field-label gform-field-label--type-inline\">Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_21_1\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_21\" type=\"radio\" value=\"Non\" id=\"choice_19_21_1\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_21_1\" id=\"label_19_21_1\" class=\"gform-field-label gform-field-label--type-inline\">Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_19_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_4col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_22\"><legend class=\"gfield_label gform-field-label\">\u00cates-vous en situation de handicap&nbsp;?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class=\"ginput_container ginput_container_radio\"><div class=\"gfield_radio\" id=\"input_19_22\">\n\t\t\t<div class=\"gchoice gchoice_19_22_0\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_22\" type=\"radio\" value=\"Aucun\" id=\"choice_19_22_0\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_22_0\" id=\"label_19_22_0\" class=\"gform-field-label gform-field-label--type-inline\">Aucun<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_22_1\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_22\" type=\"radio\" value=\"L\u00e9ger\" id=\"choice_19_22_1\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_22_1\" id=\"label_19_22_1\" class=\"gform-field-label gform-field-label--type-inline\">L\u00e9ger<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_22_2\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_22\" type=\"radio\" value=\"Moyen\" id=\"choice_19_22_2\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_22_2\" id=\"label_19_22_2\" class=\"gform-field-label gform-field-label--type-inline\">Moyen<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_22_3\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_22\" type=\"radio\" value=\"Important\" id=\"choice_19_22_3\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_22_3\" id=\"label_19_22_3\" class=\"gform-field-label gform-field-label--type-inline\">Important<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_19_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_4col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_23\"><legend class=\"gfield_label gform-field-label\">Vos moyens de d\u00e9placement<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class=\"ginput_container ginput_container_radio\"><div class=\"gfield_radio\" id=\"input_19_23\">\n\t\t\t<div class=\"gchoice gchoice_19_23_0\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_23\" type=\"radio\" value=\"\u00c0 pieds\" id=\"choice_19_23_0\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_23_0\" id=\"label_19_23_0\" class=\"gform-field-label gform-field-label--type-inline\">\u00c0 pieds<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_23_1\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_23\" type=\"radio\" value=\"Transports\" id=\"choice_19_23_1\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_23_1\" id=\"label_19_23_1\" class=\"gform-field-label gform-field-label--type-inline\">Transports<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_23_2\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_23\" type=\"radio\" value=\"Voiture\/Taxi\" id=\"choice_19_23_2\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_23_2\" id=\"label_19_23_2\" class=\"gform-field-label gform-field-label--type-inline\">Voiture\/Taxi<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_23_3\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_23\" type=\"radio\" value=\"Ambulance\" id=\"choice_19_23_3\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_23_3\" id=\"label_19_23_3\" class=\"gform-field-label gform-field-label--type-inline\">Ambulance<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_19_24\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_24\"><legend class=\"gfield_label gform-field-label\">Avez-vous \u00e9t\u00e9 suivi dans une consultation douleur auparavant&nbsp;?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class=\"ginput_container ginput_container_radio\"><div class=\"gfield_radio\" id=\"input_19_24\">\n\t\t\t<div class=\"gchoice gchoice_19_24_0\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_24\" type=\"radio\" value=\"Oui\" id=\"choice_19_24_0\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_24_0\" id=\"label_19_24_0\" class=\"gform-field-label gform-field-label--type-inline\">Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_24_1\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_24\" type=\"radio\" value=\"Non\" id=\"choice_19_24_1\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_24_1\" id=\"label_19_24_1\" class=\"gform-field-label gform-field-label--type-inline\">Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_19_25\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_25\"><label class=\"gfield_label gform-field-label\" for=\"input_19_25\">Si oui, merci de nous adresser ses coordonn\u00e9es<\/label><div class=\"ginput_container ginput_container_textarea\"><textarea name=\"input_25\" id=\"input_19_25\" class=\"textarea large\" aria-invalid=\"false\" rows=\"10\" cols=\"50\"><\/textarea><\/div><\/div><fieldset id=\"field_19_26\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_26\"><legend class=\"gfield_label gform-field-label\">Vous consultez sur les conseils de&nbsp;:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class=\"ginput_container ginput_container_radio\"><div class=\"gfield_radio\" id=\"input_19_26\">\n\t\t\t<div class=\"gchoice gchoice_19_26_0\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_26\" type=\"radio\" value=\"Votre m\u00e9decin g\u00e9n\u00e9raliste\" id=\"choice_19_26_0\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_26_0\" id=\"label_19_26_0\" class=\"gform-field-label gform-field-label--type-inline\">Votre m\u00e9decin g\u00e9n\u00e9raliste<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_26_1\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_26\" type=\"radio\" value=\"Un sp\u00e9cialiste, Lequel ?\" checked=\"checked\" id=\"choice_19_26_1\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_26_1\" id=\"label_19_26_1\" class=\"gform-field-label gform-field-label--type-inline\">Un sp\u00e9cialiste, Lequel&nbsp;?<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_26_2\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_26\" type=\"radio\" value=\"Une autre consultation douleur, Laquelle ?\" id=\"choice_19_26_2\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_26_2\" id=\"label_19_26_2\" class=\"gform-field-label gform-field-label--type-inline\">Une autre consultation douleur, Laquelle&nbsp;?<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_26_3\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_26\" type=\"radio\" value=\"A votre initiative ?\" id=\"choice_19_26_3\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_26_3\" id=\"label_19_26_3\" class=\"gform-field-label gform-field-label--type-inline\">A votre initiative&nbsp;?<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_26_4\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_26\" type=\"radio\" value=\"gf_other_choice\" id=\"choice_19_26_4\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_26_4\" id=\"label_19_26_4\" class=\"gform-field-label gform-field-label--type-inline\">Autre<\/label><br><input id=\"input_19_26_other\" class=\"gchoice_other_control\" name=\"input_26_other\" type=\"text\" value=\"Autre\" aria-label=\"Autre choix, veuillez sp\u00e9cifier\" disabled=\"disabled\">\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_19_27\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_27\"><label class=\"gfield_label gform-field-label\" for=\"input_19_27\">Un sp\u00e9cialiste, Lequel&nbsp;?<\/label><div class=\"ginput_container ginput_container_text\"><input name=\"input_27\" id=\"input_19_27\" type=\"text\" value class=\"large\" aria-invalid=\"false\"> <\/div><\/div><div id=\"field_19_29\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_29\"><label class=\"gfield_label gform-field-label\" for=\"input_19_29\">Une autre consultation douleur, Laquelle&nbsp;?<\/label><div class=\"ginput_container ginput_container_text\"><input name=\"input_29\" id=\"input_19_29\" type=\"text\" value class=\"large\" aria-invalid=\"false\"> <\/div><\/div><fieldset id=\"field_19_30\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_3col field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_30\"><legend class=\"gfield_label gform-field-label\">Qu\u2019attendez-vous de cette consultation&nbsp;?<\/legend><div class=\"ginput_container ginput_container_radio\"><div class=\"gfield_radio\" id=\"input_19_30\">\n\t\t\t<div class=\"gchoice gchoice_19_30_0\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_30\" type=\"radio\" value=\"Un \u00e9clairage diagnostique\" id=\"choice_19_30_0\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_30_0\" id=\"label_19_30_0\" class=\"gform-field-label gform-field-label--type-inline\">Un \u00e9clairage diagnostique<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_30_1\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_30\" type=\"radio\" value=\"Une r\u00e9\u00e9valuation de votre traitement m\u00e9dicamenteux\" id=\"choice_19_30_1\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_30_1\" id=\"label_19_30_1\" class=\"gform-field-label gform-field-label--type-inline\">Une r\u00e9\u00e9valuation de votre traitement m\u00e9dicamenteux<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_30_2\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_30\" type=\"radio\" value=\"Une aide non m\u00e9dicamenteuse pour mieux g\u00e9rer cette douleur\" id=\"choice_19_30_2\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_30_2\" id=\"label_19_30_2\" class=\"gform-field-label gform-field-label--type-inline\">Une aide non m\u00e9dicamenteuse pour mieux g\u00e9rer cette douleur<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_19_31\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_4col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_31\"><legend class=\"gfield_label gform-field-label\">D\u00e9but de votre douleur Depuis quand avez-vous mal&nbsp;?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class=\"ginput_container ginput_container_radio\"><div class=\"gfield_radio\" id=\"input_19_31\">\n\t\t\t<div class=\"gchoice gchoice_19_31_0\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_31\" type=\"radio\" value=\"3 mois \u00e0 6 mois\" id=\"choice_19_31_0\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_31_0\" id=\"label_19_31_0\" class=\"gform-field-label gform-field-label--type-inline\">3 mois \u00e0 6&nbsp;mois<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_31_1\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_31\" type=\"radio\" value=\"6 mois \u00e0 1 an\" id=\"choice_19_31_1\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_31_1\" id=\"label_19_31_1\" class=\"gform-field-label gform-field-label--type-inline\">6 mois \u00e0 1&nbsp;an<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_31_2\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_31\" type=\"radio\" value=\"1 \u00e0 5 ans\" id=\"choice_19_31_2\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_31_2\" id=\"label_19_31_2\" class=\"gform-field-label gform-field-label--type-inline\">1 \u00e0 5&nbsp;ans<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_31_3\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_31\" type=\"radio\" value=\"Plus de 5 ans\" id=\"choice_19_31_3\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_31_3\" id=\"label_19_31_3\" class=\"gform-field-label gform-field-label--type-inline\">Plus de 5&nbsp;ans<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_19_33\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_33\"><label class=\"gfield_label gform-field-label\" for=\"input_19_33\">La douleur est-elle apparue apr\u00e8s une chirurgie ou un traumatisme physique&nbsp;? (Si oui, pr\u00e9cisez)<\/label><div class=\"ginput_container ginput_container_textarea\"><textarea name=\"input_33\" id=\"input_19_33\" class=\"textarea large\" aria-invalid=\"false\" rows=\"10\" cols=\"50\"><\/textarea><\/div><\/div><div id=\"field_19_34\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_34\"><label class=\"gfield_label gform-field-label\" for=\"input_19_34\">La douleur est-elle apparue apr\u00e8s une maladie ou un traitement&nbsp;? (Si oui, pr\u00e9cisez)<\/label><div class=\"ginput_container ginput_container_textarea\"><textarea name=\"input_34\" id=\"input_19_34\" class=\"textarea large\" aria-invalid=\"false\" rows=\"10\" cols=\"50\"><\/textarea><\/div><\/div><div id=\"field_19_36\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_36\"><label class=\"gfield_label gform-field-label\" for=\"input_19_36\">La douleur est-elle apparue dans d\u2019autres circonstances&nbsp;? (Si oui, pr\u00e9cisez)<\/label><div class=\"ginput_container ginput_container_textarea\"><textarea name=\"input_36\" id=\"input_19_36\" class=\"textarea large\" aria-invalid=\"false\" rows=\"10\" cols=\"50\"><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class=\"gform_page_footer top_label\">\n                         <input type=\"button\" id=\"gform_next_button_19_59\" class=\"gform_next_button gform-theme-button button\" value=\"Suivant\" onclick=\"jQuery(&quot;#gform_target_page_number_19&quot;).val(&quot;2&quot;);  jQuery(&quot;#gform_19&quot;).trigger(&quot;submit&quot;,[true]); \" onkeypress=\"if( event.keyCode == 13 ){ jQuery(&quot;#gform_target_page_number_19&quot;).val(&quot;2&quot;);  jQuery(&quot;#gform_19&quot;).trigger(&quot;submit&quot;,[true]); } \"> \n                    <\/div>\n                <\/div>\n                <div id=\"gform_page_19_2\" class=\"gform_page\" data-js=\"page-field-id-59\" style=\"display:none;\">\n                    <div class=\"gform_page_fields\">\n                        <div id=\"gform_fields_19_2\" class=\"gform_fields top_label form_sublabel_below description_below\"><div id=\"field_19_64\" class=\"gfield gfield--type-html gfield--width-full 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_19_64\"><script type=\"text\/javascript\">\ngform.addFilter('image_hopper_filepond_config', function(config, FilePond, $form, currentPage, formId, fieldId, entryId, files, inputField) {\n   config.files = [\n        {\n                source: 'https:\/\/plateforme.hopital-foch.com\/wp-content\/uploads\/2022\/05\/douleurs-cetd.png', \/\/change this to the URL of your image\n                options: {\n                        type: 'input' \/\/ change 'input' to 'local' if you do not want the image auto-uploaded\n                }\n        }\n   ]\n   return config\n} )\ngform.addFilter('image_hopper_filepond_config', function(config, FilePond, $form, currentPage, formId, fieldId, entryId, files, inputField) {\n   config.allowReorder = false,\n   config.allowDrop = false,\n   config.allowBrowse = false,\n   config.allowPaste = false,\n   config.allowMultiple = false,\n   config.allowReplace = false,\n   config.allowRemove = false\n   return config\n} )\n<\/script>\n<style>\n.filepond--file-info, .PinturaModal .PinturaPicker, .PinturaColorPickerPanel .PinturaPicker\u00a0{display: none!important;}\n.PinturaColorPickerPanel ul.PinturaRadioGroupOptions li:nth-child(1), .PinturaColorPickerPanel ul.PinturaRadioGroupOptions li:nth-child(2), .PinturaColorPickerPanel ul.PinturaRadioGroupOptions li:nth-child(3), .PinturaColorPickerPanel ul.PinturaRadioGroupOptions li:nth-child(4), .PinturaColorPickerPanel ul.PinturaRadioGroupOptions li:nth-child(5), .PinturaColorPickerPanel ul.PinturaRadioGroupOptions li:nth-child(6), .PinturaColorPickerPanel ul.PinturaRadioGroupOptions li:nth-child(8), .PinturaColorPickerPanel ul.PinturaRadioGroupOptions li:nth-child(9), .PinturaColorPickerPanel ul.PinturaRadioGroupOptions li:nth-child(10), .PinturaColorPickerPanel ul.PinturaRadioGroupOptions li:nth-child(13), .PinturaColorPickerPanel ul.PinturaRadioGroupOptions li:nth-child(15), .PinturaColorPickerPanel ul.PinturaRadioGroupOptions li:nth-child(16), .PinturaColorPickerPanel ul.PinturaRadioGroupOptions li:nth-child(17){\n    display: none!important;\n}\n\/* Force the images to display in a one column layout, no matter the device *\/\n.filepond--root[data-size=\"small\"] .filepond--item,\n.filepond--root[data-size=\"medium\"] .filepond--item,\n.filepond--root[data-size=\"large\"] .filepond--item {\n    width: 100%!important;\n}\n\/* Remove the drop zone background color *\/\n.filepond--panel-root {\n\tbackground-color: inherit!important; \/* no background *\/\n}\n<\/style><\/div><div id=\"field_19_63\" class=\"gfield gfield--type-image_hopper gfield--width-full field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_63\"><label class=\"gfield_label gform-field-label\" for=\"gform_browse_button_19_63\">Description de votre douleur<\/label><div class=\"ginput_container ginput_container_image_hopper gform-theme__no-reset--children\"><input name=\"input_63\" id=\"input_19_63\" type=\"file\" data-max-files=\"4\" data-max-file-size=\"10MB\" data-image-preview-max-file-size=\"10MB\" data-image-transform-output-quality=\"90\" data-allow-image-crop=\"false\" data-image-resize-upscale=\"false\" data-image-validate-size-min-width=\"1\" data-image-validate-size-min-height=\"1\" class=\" \" aria-invalid=\"false\" data-form-id=\"19\" data-field-id=\"63\" data-files data-nonce=\"42f4ec8991\" data-min-image-warning data-min-image-warning-width data-min-image-warning-height data-editor=\"{&quot;enableEditor&quot;:true,&quot;instantEdit&quot;:false,&quot;cropToSize&quot;:&quot;&quot;,&quot;upscaleImageToCropSize&quot;:&quot;&quot;,&quot;defaultEditorView&quot;:&quot;field_markup&quot;,&quot;defaultFilter&quot;:&quot;&quot;,&quot;editorAppearance&quot;:&quot;auto&quot;,&quot;enabledFeatures&quot;:{&quot;field_crop&quot;:false,&quot;field_rotate_left&quot;:false,&quot;field_rotate_right&quot;:false,&quot;field_manual_rotation&quot;:false,&quot;field_markup&quot;:true,&quot;field_draw&quot;:true,&quot;field_arrow&quot;:true,&quot;field_flip_horizontal&quot;:false,&quot;field_flip_vertical&quot;:false,&quot;field_show_size&quot;:false,&quot;field_redact&quot;:false,&quot;field_circle&quot;:true}}\"><\/div><div class=\"gfield_description\" id=\"gfield_description_19_63\">Localisez sur les sch\u00e9mas ci-dessous  l\u2019endroit  o\u00f9 vous ressentez votre douleur en utilisant le code couleur propos\u00e9&nbsp;: \n<span style=\"color:red;\">Rouge<\/span> \u2192 Tr\u00e8s intense, <span style=\"color:yellow;\">Jaune<\/span> \u2192 Intense, <span style=\"color:green;\">Vert<\/span> \u2192 moyenne, <span style=\"color:blue;\">Bleu<\/span> \u2192 Faible.&nbsp;<\/div><\/div><\/div>\n                    <\/div>\n                    <div class=\"gform_page_footer top_label\">\n                        <input type=\"button\" id=\"gform_previous_button_19_62\" class=\"gform_previous_button gform-theme-button gform-theme-button--secondary button\" value=\"Pr\u00e9c\u00e9dent\" onclick=\"jQuery(&quot;#gform_target_page_number_19&quot;).val(&quot;1&quot;);  jQuery(&quot;#gform_19&quot;).trigger(&quot;submit&quot;,[true]); \" onkeypress=\"if( event.keyCode == 13 ){ jQuery(&quot;#gform_target_page_number_19&quot;).val(&quot;1&quot;);  jQuery(&quot;#gform_19&quot;).trigger(&quot;submit&quot;,[true]); } \"> <input type=\"button\" id=\"gform_next_button_19_62\" class=\"gform_next_button gform-theme-button button\" value=\"Suivant\" onclick=\"jQuery(&quot;#gform_target_page_number_19&quot;).val(&quot;3&quot;);  jQuery(&quot;#gform_19&quot;).trigger(&quot;submit&quot;,[true]); \" onkeypress=\"if( event.keyCode == 13 ){ jQuery(&quot;#gform_target_page_number_19&quot;).val(&quot;3&quot;);  jQuery(&quot;#gform_19&quot;).trigger(&quot;submit&quot;,[true]); } \"> \n                    <\/div>\n                <\/div>\n                <div id=\"gform_page_19_3\" class=\"gform_page\" data-js=\"page-field-id-62\" style=\"display:none;\">\n                    <div class=\"gform_page_fields\">\n                        <div id=\"gform_fields_19_3\" class=\"gform_fields top_label form_sublabel_below description_below\"><div id=\"field_19_38\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_38\"><h3 class=\"gsection_title\">PARTIE \u00c0 REMPLIR PAR VOTRE M\u00c9DECIN<\/h3><div class=\"gsection_description\" id=\"gfield_description_19_38\">A qui le compte rendu de votre consultation sera adress\u00e9.&nbsp;<\/div><\/div><div id=\"field_19_39\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_39\"><label class=\"gfield_label gform-field-label\" for=\"input_19_39\">1- Type ou \u00e9tiologie de la douleur motivant la consultation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class=\"ginput_container ginput_container_textarea\"><textarea name=\"input_39\" id=\"input_19_39\" class=\"textarea large\" aria-required=\"true\" aria-invalid=\"false\" rows=\"10\" cols=\"50\"><\/textarea><\/div><\/div><fieldset id=\"field_19_40\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_4col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_40\"><legend class=\"gfield_label gform-field-label\">Contexte urgent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class=\"ginput_container ginput_container_radio\"><div class=\"gfield_radio\" id=\"input_19_40\">\n\t\t\t<div class=\"gchoice gchoice_19_40_0\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_40\" type=\"radio\" value=\"Post partum\" id=\"choice_19_40_0\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_40_0\" id=\"label_19_40_0\" class=\"gform-field-label gform-field-label--type-inline\">Post partum<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_40_1\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_40\" type=\"radio\" value=\"Post chirurgical\" id=\"choice_19_40_1\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_40_1\" id=\"label_19_40_1\" class=\"gform-field-label gform-field-label--type-inline\">Post chirurgical<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_40_2\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_40\" type=\"radio\" value=\"Oncologique\" id=\"choice_19_40_2\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_40_2\" id=\"label_19_40_2\" class=\"gform-field-label gform-field-label--type-inline\">Oncologique<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_40_3\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_40\" type=\"radio\" value=\"Post zona\" id=\"choice_19_40_3\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_40_3\" id=\"label_19_40_3\" class=\"gform-field-label gform-field-label--type-inline\">Post zona<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_19_41\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_5col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_41\"><legend class=\"gfield_label gform-field-label\">D\u00e9lai d\u2019apparition<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class=\"ginput_container ginput_container_radio\"><div class=\"gfield_radio\" id=\"input_19_41\">\n\t\t\t<div class=\"gchoice gchoice_19_41_0\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_41\" type=\"radio\" value=\"1-3 mois\" id=\"choice_19_41_0\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_41_0\" id=\"label_19_41_0\" class=\"gform-field-label gform-field-label--type-inline\">1\u20133 mois<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_41_1\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_41\" type=\"radio\" value=\"3-6 mois\" id=\"choice_19_41_1\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_41_1\" id=\"label_19_41_1\" class=\"gform-field-label gform-field-label--type-inline\">3\u20136 mois<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_41_2\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_41\" type=\"radio\" value=\"6 mois-1an\" id=\"choice_19_41_2\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_41_2\" id=\"label_19_41_2\" class=\"gform-field-label gform-field-label--type-inline\">6 mois-1an<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_41_3\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_41\" type=\"radio\" value=\"1-5 ans\" id=\"choice_19_41_3\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_41_3\" id=\"label_19_41_3\" class=\"gform-field-label gform-field-label--type-inline\">1\u20135 ans<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_41_4\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_41\" type=\"radio\" value=\">5 ans\" id=\"choice_19_41_4\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_41_4\" id=\"label_19_41_4\" class=\"gform-field-label gform-field-label--type-inline\">&gt;5 ans<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_19_42\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_42\"><legend class=\"gfield_label gform-field-label\">2- Votre patient est-il en ALD pour ce probl\u00e8me douloureux&nbsp;?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class=\"ginput_container ginput_container_radio\"><div class=\"gfield_radio\" id=\"input_19_42\">\n\t\t\t<div class=\"gchoice gchoice_19_42_0\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_42\" type=\"radio\" value=\"Oui\" id=\"choice_19_42_0\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_42_0\" id=\"label_19_42_0\" class=\"gform-field-label gform-field-label--type-inline\">Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_42_1\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_42\" type=\"radio\" value=\"Non\" id=\"choice_19_42_1\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_42_1\" id=\"label_19_42_1\" class=\"gform-field-label gform-field-label--type-inline\">Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_19_43\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_43\"><label class=\"gfield_label gform-field-label\" for=\"input_19_43\">3- Ant\u00e9c\u00e9dents principaux du patient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class=\"ginput_container ginput_container_textarea\"><textarea name=\"input_43\" id=\"input_19_43\" class=\"textarea large\" aria-required=\"true\" aria-invalid=\"false\" rows=\"10\" cols=\"50\"><\/textarea><\/div><\/div><div id=\"field_19_44\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_44\"><label class=\"gfield_label gform-field-label\" for=\"input_19_44\">4\u2011Traitement m\u00e9dicamenteux en cours (ou joindre l\u2019ordonnance)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class=\"ginput_container ginput_container_textarea\"><textarea name=\"input_44\" id=\"input_19_44\" class=\"textarea large\" aria-required=\"true\" aria-invalid=\"false\" rows=\"10\" cols=\"50\"><\/textarea><\/div><\/div><fieldset id=\"field_19_46\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_46\"><legend class=\"gfield_label gform-field-label\">5- Motifs de la consultation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class=\"ginput_container ginput_container_radio\"><div class=\"gfield_radio\" id=\"input_19_46\">\n\t\t\t<div class=\"gchoice gchoice_19_46_0\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_46\" type=\"radio\" value=\"Avis diagnostique\" id=\"choice_19_46_0\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_46_0\" id=\"label_19_46_0\" class=\"gform-field-label gform-field-label--type-inline\">Avis diagnostique<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_46_1\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_46\" type=\"radio\" value=\"R\u00e9\u00e9valuation du traitement m\u00e9dicamenteux\" id=\"choice_19_46_1\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_46_1\" id=\"label_19_46_1\" class=\"gform-field-label gform-field-label--type-inline\">R\u00e9\u00e9valuation du traitement m\u00e9dicamenteux<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_46_2\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_46\" type=\"radio\" value=\"Prise en charge de la douleur interventionnelle (infiltration nerveuse- bloc nerveux, mise en place de pompe intrath\u00e9cale, stimulation m\u00e9dullaire ou nerveuse)\" id=\"choice_19_46_2\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_46_2\" id=\"label_19_46_2\" class=\"gform-field-label gform-field-label--type-inline\">Prise en charge de la douleur interventionnelle (infiltration nerveuse- bloc nerveux, mise en place de pompe intrath\u00e9cale, stimulation m\u00e9dullaire ou nerveuse)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_46_3\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_46\" type=\"radio\" value=\"Demande de prise en charge non m\u00e9dicamenteuse :(Electrostimulation (TENS),  tech-niques psychocorporelles, auriculoth\u00e9rapie)\" id=\"choice_19_46_3\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_46_3\" id=\"label_19_46_3\" class=\"gform-field-label gform-field-label--type-inline\">Demande de prise en charge non m\u00e9dicamenteuse :(Electrostimulation (TENS),  tech-niques psychocorporelles, auriculoth\u00e9rapie)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_19_46_4\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_46\" type=\"radio\" value=\"Consultation demand\u00e9e par le patient\" id=\"choice_19_46_4\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_19_46_4\" id=\"label_19_46_4\" class=\"gform-field-label gform-field-label--type-inline\">Consultation demand\u00e9e par le patient<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_19_47\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_47\"><label class=\"gfield_label gform-field-label\" for=\"input_19_47\">6- Examens compl\u00e9mentaires r\u00e9alis\u00e9s pour l\u2019exploration de cette douleur (ou double des comptes rendus)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class=\"ginput_container ginput_container_textarea\"><textarea name=\"input_47\" id=\"input_19_47\" class=\"textarea large\" aria-required=\"true\" aria-invalid=\"false\" rows=\"10\" cols=\"50\"><\/textarea><\/div><\/div><div id=\"field_19_48\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_48\"><label class=\"gfield_label gform-field-label\" for=\"input_19_48\">7- Sp\u00e9cialistes consult\u00e9s pour cette douleur chronique (rhumatologue, chirurgien, neurologue, psychologue, interniste, psychiatre\u2026 (Merci de joindre les comptes rendus de consultation)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class=\"ginput_container ginput_container_textarea\"><textarea name=\"input_48\" id=\"input_19_48\" class=\"textarea large\" aria-required=\"true\" aria-invalid=\"false\" rows=\"10\" cols=\"50\"><\/textarea><\/div><\/div><div id=\"field_19_49\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_49\"><label class=\"gfield_label gform-field-label\" for=\"input_19_49\">8- Le patient a\u2011t-il d\u00e9j\u00e0 \u00e9t\u00e9 hospitalis\u00e9 pour cette douleur notamment dans un centre de  r\u00e9\u00e9ducation fonctionnelle ou d\u00e9j\u00e0 dans un autre CETD&nbsp;?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class=\"ginput_container ginput_container_textarea\"><textarea name=\"input_49\" id=\"input_19_49\" class=\"textarea large\" aria-required=\"true\" aria-invalid=\"false\" rows=\"10\" cols=\"50\"><\/textarea><\/div><\/div><fieldset id=\"field_19_50\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_4col gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_50\"><legend class=\"gfield_label gform-field-label gfield_label_before_complex\">9- M\u00e9dicaments d\u00e9j\u00e0 essay\u00e9s pour soulager cette douleur<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class=\"ginput_container ginput_container_checkbox\"><div class=\"gfield_checkbox\" id=\"input_19_50\"><div class=\"gchoice gchoice_19_50_1\">\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_50.1\" type=\"checkbox\" value=\"Parac\u00e9tamol\" id=\"choice_19_50_1\">\n\t\t\t\t\t\t\t\t<label for=\"choice_19_50_1\" id=\"label_19_50_1\" class=\"gform-field-label gform-field-label--type-inline\">Parac\u00e9tamol<\/label>\n\t\t\t\t\t\t\t<\/div><div class=\"gchoice gchoice_19_50_2\">\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_50.2\" type=\"checkbox\" value=\"Aspirine\" id=\"choice_19_50_2\">\n\t\t\t\t\t\t\t\t<label for=\"choice_19_50_2\" id=\"label_19_50_2\" class=\"gform-field-label gform-field-label--type-inline\">Aspirine<\/label>\n\t\t\t\t\t\t\t<\/div><div class=\"gchoice gchoice_19_50_3\">\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_50.3\" type=\"checkbox\" value=\"AINS\" id=\"choice_19_50_3\">\n\t\t\t\t\t\t\t\t<label for=\"choice_19_50_3\" id=\"label_19_50_3\" class=\"gform-field-label gform-field-label--type-inline\">AINS<\/label>\n\t\t\t\t\t\t\t<\/div><div class=\"gchoice gchoice_19_50_4\">\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_50.4\" type=\"checkbox\" value=\"Acupan\" id=\"choice_19_50_4\">\n\t\t\t\t\t\t\t\t<label for=\"choice_19_50_4\" id=\"label_19_50_4\" class=\"gform-field-label gform-field-label--type-inline\">Acupan<\/label>\n\t\t\t\t\t\t\t<\/div><div class=\"gchoice gchoice_19_50_5\">\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_50.5\" type=\"checkbox\" value=\"Ixprim\/Zaldiar\" id=\"choice_19_50_5\">\n\t\t\t\t\t\t\t\t<label for=\"choice_19_50_5\" id=\"label_19_50_5\" class=\"gform-field-label gform-field-label--type-inline\">Ixprim\/Zaldiar<\/label>\n\t\t\t\t\t\t\t<\/div><div class=\"gchoice gchoice_19_50_6\">\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_50.6\" type=\"checkbox\" value=\"Tramadol\" id=\"choice_19_50_6\">\n\t\t\t\t\t\t\t\t<label for=\"choice_19_50_6\" id=\"label_19_50_6\" class=\"gform-field-label gform-field-label--type-inline\">Tramadol<\/label>\n\t\t\t\t\t\t\t<\/div><div class=\"gchoice gchoice_19_50_7\">\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_50.7\" type=\"checkbox\" value=\"Effralgan cod\u00e9in\u00e9\/Codoliprane\/Klippal\" id=\"choice_19_50_7\">\n\t\t\t\t\t\t\t\t<label for=\"choice_19_50_7\" id=\"label_19_50_7\" class=\"gform-field-label gform-field-label--type-inline\">Effralgan cod\u00e9in\u00e9\/Codoliprane\/Klippal<\/label>\n\t\t\t\t\t\t\t<\/div><div class=\"gchoice gchoice_19_50_8\">\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_50.8\" type=\"checkbox\" value=\"Lamaline\/Izalgi\" id=\"choice_19_50_8\">\n\t\t\t\t\t\t\t\t<label for=\"choice_19_50_8\" id=\"label_19_50_8\" class=\"gform-field-label gform-field-label--type-inline\">Lamaline\/Izalgi<\/label>\n\t\t\t\t\t\t\t<\/div><div class=\"gchoice gchoice_19_50_9\">\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_50.9\" type=\"checkbox\" value=\"Skenan Actiskenan\" id=\"choice_19_50_9\">\n\t\t\t\t\t\t\t\t<label for=\"choice_19_50_9\" id=\"label_19_50_9\" class=\"gform-field-label gform-field-label--type-inline\">Skenan Actiskenan<\/label>\n\t\t\t\t\t\t\t<\/div><div class=\"gchoice gchoice_19_50_11\">\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_50.11\" type=\"checkbox\" value=\"Oxycontin Oxynorm\" id=\"choice_19_50_11\">\n\t\t\t\t\t\t\t\t<label for=\"choice_19_50_11\" id=\"label_19_50_11\" class=\"gform-field-label gform-field-label--type-inline\">Oxycontin Oxynorm<\/label>\n\t\t\t\t\t\t\t<\/div><div class=\"gchoice gchoice_19_50_12\">\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_50.12\" type=\"checkbox\" value=\"Durog\u00e9sic\" id=\"choice_19_50_12\">\n\t\t\t\t\t\t\t\t<label for=\"choice_19_50_12\" id=\"label_19_50_12\" class=\"gform-field-label gform-field-label--type-inline\">Durog\u00e9sic<\/label>\n\t\t\t\t\t\t\t<\/div><div class=\"gchoice gchoice_19_50_13\">\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_50.13\" type=\"checkbox\" value=\"Lyrica\" id=\"choice_19_50_13\">\n\t\t\t\t\t\t\t\t<label for=\"choice_19_50_13\" id=\"label_19_50_13\" class=\"gform-field-label gform-field-label--type-inline\">Lyrica<\/label>\n\t\t\t\t\t\t\t<\/div><div class=\"gchoice gchoice_19_50_14\">\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_50.14\" type=\"checkbox\" value=\"Neurotin\" id=\"choice_19_50_14\">\n\t\t\t\t\t\t\t\t<label for=\"choice_19_50_14\" id=\"label_19_50_14\" class=\"gform-field-label gform-field-label--type-inline\">Neurotin<\/label>\n\t\t\t\t\t\t\t<\/div><div class=\"gchoice gchoice_19_50_15\">\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_50.15\" type=\"checkbox\" value=\"Laroxyl\" id=\"choice_19_50_15\">\n\t\t\t\t\t\t\t\t<label for=\"choice_19_50_15\" id=\"label_19_50_15\" class=\"gform-field-label gform-field-label--type-inline\">Laroxyl<\/label>\n\t\t\t\t\t\t\t<\/div><div class=\"gchoice gchoice_19_50_16\">\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_50.16\" type=\"checkbox\" value=\"Cymbalta\" id=\"choice_19_50_16\">\n\t\t\t\t\t\t\t\t<label for=\"choice_19_50_16\" id=\"label_19_50_16\" class=\"gform-field-label gform-field-label--type-inline\">Cymbalta<\/label>\n\t\t\t\t\t\t\t<\/div><div class=\"gchoice gchoice_19_50_17\">\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_50.17\" type=\"checkbox\" value=\"Tegretol\" id=\"choice_19_50_17\">\n\t\t\t\t\t\t\t\t<label for=\"choice_19_50_17\" id=\"label_19_50_17\" class=\"gform-field-label gform-field-label--type-inline\">Tegretol<\/label>\n\t\t\t\t\t\t\t<\/div><div class=\"gchoice gchoice_19_50_18\">\n\t\t\t\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_50.18\" type=\"checkbox\" value=\"Versatis\" id=\"choice_19_50_18\">\n\t\t\t\t\t\t\t\t<label for=\"choice_19_50_18\" id=\"label_19_50_18\" class=\"gform-field-label gform-field-label--type-inline\">Versatis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_19_51\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_51\"><label class=\"gfield_label gform-field-label\" for=\"input_19_51\">10- En tant que m\u00e9decin traitant, avez-vous une demande sp\u00e9cifique \u00e0 formuler pour ce  patient ou un \u00e9clairage contextuel, motivationnel ou autre \u00e0 apporter&nbsp;?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class=\"ginput_container ginput_container_textarea\"><textarea name=\"input_51\" id=\"input_19_51\" class=\"textarea large\" aria-required=\"true\" aria-invalid=\"false\" rows=\"10\" cols=\"50\"><\/textarea><\/div><\/div><div id=\"field_19_52\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_52\"><h3 class=\"gsection_title\">Coordonn\u00e9es du m\u00e9decin<\/h3><\/div><div id=\"field_19_53\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_53\"><label class=\"gfield_label gform-field-label\" for=\"input_19_53\">Nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class=\"ginput_container ginput_container_text\"><input name=\"input_53\" id=\"input_19_53\" type=\"text\" value class=\"large\" aria-required=\"true\" aria-invalid=\"false\"> <\/div><\/div><div id=\"field_19_54\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_54\"><label class=\"gfield_label gform-field-label\" for=\"input_19_54\">Pr\u00e9nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class=\"ginput_container ginput_container_text\"><input name=\"input_54\" id=\"input_19_54\" type=\"text\" value class=\"large\" aria-required=\"true\" aria-invalid=\"false\"> <\/div><\/div><div id=\"field_19_57\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_57\"><label class=\"gfield_label gform-field-label\" for=\"input_19_57\">T\u00e9l\u00e9phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class=\"ginput_container ginput_container_text\"><input name=\"input_57\" id=\"input_19_57\" type=\"text\" value class=\"large\" aria-required=\"true\" aria-invalid=\"false\"> <\/div><\/div><div id=\"field_19_58\" class=\"gfield gfield--type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_19_58\"><label class=\"gfield_label gform-field-label\" for=\"input_19_58\">E\u2011mail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class=\"ginput_container ginput_container_email\">\n                            <input name=\"input_58\" id=\"input_19_58\" type=\"email\" value class=\"large\" aria-required=\"true\" aria-invalid=\"false\">\n                        <\/div><\/div><div id=\"field_19_60\" class=\"gfield gfield--type-html gfield--width-full 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_19_60\"><h5>En vous remerciant vivement de votre collaboration, veuillez agr\u00e9er, cher coll\u00e8gue, l\u2019exu0002pression de nos sentiments distingu\u00e9s.<\/h5><\/div><div id=\"field_19_61\" class=\"gfield gfield--type-html gfield--width-full 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_19_61\"><h5>L\u2019\u00e9quipe du CETD <br><br> H\u00f4pital Foch<\/h5><\/div><\/div><\/div>\n        <div class=\"gform_page_footer top_label\"><input type=\"submit\" id=\"gform_previous_button_19\" class=\"gform_previous_button gform-theme-button gform-theme-button--secondary button\" value=\"Pr\u00e9c\u00e9dent\" onclick=\"if(window[&quot;gf_submitting_19&quot;]){return false;}  if( !jQuery(&quot;#gform_19&quot;)[0].checkValidity || jQuery(&quot;#gform_19&quot;)[0].checkValidity()){window[&quot;gf_submitting_19&quot;]=true;}  \" onkeypress=\"if( event.keyCode == 13 ){ if(window[&quot;gf_submitting_19&quot;]){return false;} if( !jQuery(&quot;#gform_19&quot;)[0].checkValidity || jQuery(&quot;#gform_19&quot;)[0].checkValidity()){window[&quot;gf_submitting_19&quot;]=true;}  jQuery(&quot;#gform_19&quot;).trigger(&quot;submit&quot;,[true]); }\"> <input type=\"submit\" id=\"gform_submit_button_19\" class=\"gform_button button\" value=\"Envoyer\" 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Pour nous permettre de r\u00e9pondre au mieux \u00e0 votre demande, nous vous invitons \u00e0 compl\u00e9ter le document ci-joint qui comprend une partie \u00e0 faire remplir par votre m\u00e9decin r\u00e9f\u00e9rent.Ce document doit \u00eatre adress\u00e9 au secr\u00e9tariat du&nbsp; CETD par voie postale Institut Line&nbsp;\u2026<\/p>\n<p class=\"read-more\"> <a class href=\"https:\/\/plateforme.hopital-foch.com\/fr\/questionnaire-douleur\/\"> <span class=\"screen-reader-text\">Questionnaire douleur<\/span> Lire la&nbsp;suite&nbsp;\u00bb<\/a><\/p>\n","protected":false},"author":12,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"inline_featured_image":false,"wp_typography_post_enhancements_disabled":false,"site-sidebar-layout":"no-sidebar","site-content-layout":"page-builder","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"disabled","ast-breadcrumbs-content":"","ast-featured-img":"disabled","footer-sml-layout":"","theme-transparent-header-meta":"default","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":""},"_links":{"self":[{"href":"https:\/\/plateforme.hopital-foch.com\/fr\/wp-json\/wp\/v2\/pages\/1086"}],"collection":[{"href":"https:\/\/plateforme.hopital-foch.com\/fr\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/plateforme.hopital-foch.com\/fr\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/plateforme.hopital-foch.com\/fr\/wp-json\/wp\/v2\/users\/12"}],"replies":[{"embeddable":true,"href":"https:\/\/plateforme.hopital-foch.com\/fr\/wp-json\/wp\/v2\/comments?post=1086"}],"version-history":[{"count":17,"href":"https:\/\/plateforme.hopital-foch.com\/fr\/wp-json\/wp\/v2\/pages\/1086\/revisions"}],"predecessor-version":[{"id":1178,"href":"https:\/\/plateforme.hopital-foch.com\/fr\/wp-json\/wp\/v2\/pages\/1086\/revisions\/1178"}],"wp:attachment":[{"href":"https:\/\/plateforme.hopital-foch.com\/fr\/wp-json\/wp\/v2\/media?parent=1086"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}