{"id":4272145033,"date":"2025-09-11T14:31:20","date_gmt":"2025-09-11T14:31:20","guid":{"rendered":"https:\/\/neuronicdev.es\/deep-sea-world\/?page_id=4272145033"},"modified":"2025-09-15T15:42:52","modified_gmt":"2025-09-15T15:42:52","slug":"medical-form-qualified","status":"publish","type":"page","link":"https:\/\/neuronicdev.es\/deep-sea-world\/medical-form-qualified\/","title":{"rendered":"Medical Form (qualified)"},"content":{"rendered":"        <div class=\"diving-medical-form\" id=\"diving-form-69e0afeedd69e\"\n             data-form-type=\"qualified\"\n             data-booking-ref=\"\"\n             data-participant-index=\"\"\n             data-token=\"\">\n            \n                    <div class=\"form-header\">\n            <div class=\"certification-logos\">\n                            <\/div>\n            \n                            <h1 class=\"form-title\">Qualified Dive<\/h1>\n                <h2 class=\"form-subtitle\">Participant Questionnaire<\/h2>\n                        \n            <p class=\"form-description\">\n                Recreational scuba diving and freediving requires good physical and mental health. This questionnaire helps determine if you should seek medical evaluation before diving.            <\/p>\n        <\/div>\n                    \n            <form class=\"wpdmf-form\" method=\"post\">\n                <input type=\"hidden\" id=\"wpdmf_nonce\" name=\"wpdmf_nonce\" value=\"176d903353\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/deep-sea-world\/wp-json\/wp\/v2\/pages\/4272145033\" \/>                \n                <!-- Step 1: Personal Details -->\n                <div class=\"form-step active\" data-step-key=\"participant_info\">\n                            <div class=\"participant-info-section\">\n                            <div class=\"medical-notice\">\n                    <p>Please provide your personal details and diving qualifications below.<\/p>\n                    <div class=\"form-requirements\">\n                        <h5 style=\"margin-top:10px;\">What to bring:<\/h5>\n                        <ul style=\"margin-block:10px;\">\n                            <li>Must bring log book with a dive in the past 6 months<\/li>\n                            <li>Must bring certification card<\/li>\n                            <li>Must be qualified divers with appropriate certifications<\/li>\n                            <li>Under 18 must have parent\/guardian present<\/li>\n                        <\/ul>\n                    <\/div>\n                    <p><strong>Note to women:<\/strong> If you are pregnant, or attempting to become pregnant, do not dive.<\/p>\n                <\/div>\n                        \n            <div class=\"form-fields-grid\">\n                <div class=\"field-group\">\n                    <label for=\"participant_name\">Full Name <span class=\"required\">*<\/span><\/label>\n                    <input type=\"text\" id=\"participant_name\" name=\"participant_name\" required>\n                <\/div>\n                \n                <div class=\"field-group\">\n                    <label for=\"participant_email\">Email Address <span class=\"required\">*<\/span><\/label>\n                    <input type=\"email\" id=\"participant_email\" name=\"participant_email\" required>\n                <\/div>\n                \n                <div class=\"field-group\">\n                    <label for=\"participant_phone\">Phone Number <span class=\"required\">*<\/span><\/label>\n                    <input type=\"tel\" id=\"participant_phone\" name=\"participant_phone\" required>\n                <\/div>\n                \n                <div class=\"field-group\">\n                    <label for=\"participant_birthdate\">Date of Birth <span class=\"required\">*<\/span><\/label>\n                    <input type=\"date\" id=\"participant_birthdate\" name=\"participant_birthdate\" required>\n                <\/div>\n                \n                <div class=\"field-group full-width\">\n                    <label for=\"participant_address\">Address <span class=\"required\">*<\/span><\/label>\n                    <textarea id=\"participant_address\" name=\"participant_address\" rows=\"3\" required placeholder=\"Enter your full address\"><\/textarea>\n                <\/div>\n                \n                <div class=\"field-group\">\n                    <label for=\"emergency_contact_name\">Emergency Contact Name <span class=\"required\">*<\/span><\/label>\n                    <input type=\"text\" id=\"emergency_contact_name\" name=\"emergency_contact_name\" required>\n                <\/div>\n                \n                <div class=\"field-group\">\n                    <label for=\"emergency_contact_phone\">Emergency Contact Phone <span class=\"required\">*<\/span><\/label>\n                    <input type=\"tel\" id=\"emergency_contact_phone\" name=\"emergency_contact_phone\" required>\n                <\/div>\n                \n                <div class=\"field-group conditional-minor-field\" style=\"display: none;\">\n                    <label for=\"parent_guardian_signature\">Parent\/Guardian Signature <span class=\"required\">*<\/span><\/label>\n                    <input type=\"text\" id=\"parent_guardian_signature\" name=\"parent_guardian_signature\" placeholder=\"Type parent\/guardian full name to sign\">\n                    <p class=\"field-note\">Required for participants under 18 years of age<\/p>\n                <\/div>\n                \n                                    <div class=\"field-group\">\n                        <label for=\"certification_level\">Certification Level <span class=\"required\">*<\/span><\/label>\n                        <select id=\"certification_level\" name=\"certification_level\" required>\n                            <option value=\"\">Select certification level<\/option>\n                            <option value=\"open_water\">Open Water Diver<\/option>\n                            <option value=\"advanced\">Advanced Open Water<\/option>\n                            <option value=\"rescue\">Rescue Diver<\/option>\n                            <option value=\"divemaster\">Divemaster<\/option>\n                            <option value=\"instructor\">Instructor<\/option>\n                            <option value=\"other\">Other<\/option>\n                        <\/select>\n                    <\/div>\n                    \n                    <div class=\"field-group\">\n                        <label for=\"certification_agency\">Certification Agency <span class=\"required\">*<\/span><\/label>\n                        <select id=\"certification_agency\" name=\"certification_agency\" required>\n                            <option value=\"\">Select certification agency<\/option>\n                            <option value=\"padi\">PADI<\/option>\n                            <option value=\"ssi\">SSI<\/option>\n                            <option value=\"bsac\">BSAC<\/option>\n                            <option value=\"naui\">NAUI<\/option>\n                            <option value=\"other\">Other<\/option>\n                        <\/select>\n                    <\/div>\n                    \n                    <div class=\"field-group\">\n                        <label for=\"last_dive_date\">Date of Last Dive (within past 6 months) <span class=\"required\">*<\/span><\/label>\n                        <input type=\"date\" id=\"last_dive_date\" name=\"last_dive_date\" required>\n                    <\/div>\n                    \n                    <div class=\"field-group\">\n                        <label for=\"total_dives\">Total Number of Dives <span class=\"required\">*<\/span><\/label>\n                        <input type=\"number\" id=\"total_dives\" name=\"total_dives\" min=\"1\" required>\n                    <\/div>\n                            <\/div>\n        <\/div>\n                            <div class=\"step-navigation\">\n                        <button type=\"button\" class=\"btn btn-secondary\" disabled>Back<\/button>\n                        <button type=\"button\" class=\"btn btn-primary\" data-action=\"next\">Continue<\/button>\n                    <\/div>\n                <\/div>\n                \n                <!-- Step 2: Terms & Conditions -->\n                <div class=\"form-step\" data-step-key=\"terms_conditions\" style=\"display: none;\">\n                            <div class=\"terms-conditions-section\">\n            <h3>Terms & Conditions<\/h3>\n            <div class=\"terms-content\">\n                <div class=\"terms-text\">\n                    <strong>Terms and Conditions for Dive Vouchers<\/strong>\r\n<ul>\r\n \t<li>Gift vouchers for Shark Encounters and Junior Shark Encounters are valid for either 3 or 6 months from the date of purchase. Gift vouchers for Shark Dive Nights and Shark Awareness Courses are valid for 12 months from the date of purchase. This validity will be detailed on the voucher itself.<\/li>\r\n \t<li>Deep Sea World will only issue Dive Gift Vouchers upon receipt of full payment<\/li>\r\n \t<li>Any extension to the voucher validity period is at the discretion of Deep Sea World and must be authorised prior to the voucher expiry date. An administration fee of \u00a325 will be incurred to extend the voucher for each successive 3 month period beyond the original expiry date.<\/li>\r\n \t<li>Deep Sea World reserves the right to cancel, alter or amend any of the prices, times and dates without notice should operational or other circumstances require us to do so.<\/li>\r\n \t<li>If Deep Sea World cancels, postpones or alters any of the dive events at any given time the participant accepts that Deep Sea World is not responsible or liable for any external costs. Examples would include travel costs and hotel costs (NB: This list is not exhaustive)<\/li>\r\n \t<li>If the diver fails to appear for the dive without prior notification the dive and all payments will be forfeited. You must contact our bookings team on 01383 411880 if you are unable to attend.<\/li>\r\n \t<li>If you are unable to participate on the given day, we will be happy to reschedule your dive provided no less than 14 days notice is given. This 14 day notice period will be strictly adhered to. If the diver gives less than 14 days notice then an administration fee of \u00a325 will be charged to rearrange the date.<\/li>\r\n \t<li>Once the pool training and\/or briefings have begun, no refunds will be given unless operational issues force Deep Sea World staff to cancel the dive.<\/li>\r\n \t<li>It is mandatory to complete a PADI medical disclaimer prior to the dive. This is a basic health questionnaire. If the diver answers \u2018YES\u2019 to any of the questions on the form , please contact us as the diver will require an additional form to be signed by their GP prior to commencing the dive. Please note \u2013 doctors may charge fees for this service.<\/li>\r\n \t<li>If this is a surprise gift, please be aware that if the diver answers \u2018YES\u2019 to one or more of the questions on the PADI medical form, their dive must be authorised by their GP or Diving GP depending on the nature of the problem, please contact us for advice. Without medical authorisation the dive will not go ahead.<\/li>\r\n \t<li>Deep Sea World Dive Instructors reserve the right to refuse the medical note, if they feel the diver is unsuitable to participate and could possibly jeopardise the Health and Safety of themselves and other participants.<\/li>\r\n \t<li>All dive experiences are non-refundable, unless the diver is medically unfit to participate. In this case we will require a medical exemption form to be signed off by a GP. Upon receipt of medical exemption, Deep Sea World will issue a refund in the form of a cheque. All refunds are minus a \u00a325 administration fee. Dive vouchers may be transferred to another person but in this circumstance the voucher expiry date will remain the same.<\/li>\r\n \t<li>All divers must present their letter of confirmation from our Booking Department on arrival.<\/li>\r\n \t<li>Non-qualified divers or divers wishing to take part in the Shark Encounter must be at least 16 years of age and in reasonable health. Non-qualified divers wishing to take part in the Junior Shark Encounter must be at least 8 years of age and in reasonable health.<\/li>\r\n \t<li>Equipment hire for Shark Dive programs, must be pre-booked and paid for at least 7 days prior to the event. Payment can be made by debit or credit card over the phone. All damages to hired equipment must be paid for in full.<\/li>\r\n \t<li>For the Shark Dive and Shark Awareness programs all qualified divers must bring all dive certifications, current and up to date log books, or proof of dives within the last 6 months. Failure to do so will result in the cancellation of your dive and no refunds will be given.<\/li>\r\n \t<li>Qualified divers must have a minimum of one logged dive within the last 6 months prior to the event.<\/li>\r\n \t<li>Qualified divers under the age of 16 must have a parent or legal guardian present on the day of the event. Qualified divers under the age of 12 must be accompanied by a parent or legal guardian that is a qualified diver and WHO WILL DIVE WITH THE CHILD.<\/li>\r\n \t<li>Deep Sea World cannot accept responsibility for any personal items damaged or lost within the attraction, surrounding grounds or car park. We recommend items of value are left at home.<\/li>\r\n<\/ul>                <\/div>\n            <\/div>\n            \n            <div class=\"form-fields-grid\">\n                <div class=\"field-group\">\n                    <label for=\"terms_full_name\">Full Name <span class=\"required\">*<\/span><\/label>\n                    <input type=\"text\" id=\"terms_full_name\" name=\"terms_full_name\" required>\n                <\/div>\n                \n                <div class=\"field-group full-width\">\n                    <label for=\"terms_address\">Address <span class=\"required\">*<\/span><\/label>\n                    <textarea id=\"terms_address\" name=\"terms_address\" rows=\"3\" required><\/textarea>\n                <\/div>\n                \n                <div class=\"field-group\">\n                    <label for=\"terms_signature\">Signature <span class=\"required\">*<\/span><\/label>\n                    <input type=\"text\" id=\"terms_signature\" name=\"terms_signature\" required placeholder=\"Type your full name to sign\">\n                <\/div>\n                \n                <div class=\"field-group\">\n                    <label for=\"terms_date\">Date <span class=\"required\">*<\/span><\/label>\n                    <input type=\"date\" id=\"terms_date\" name=\"terms_date\" required value=\"2026-04-16\">\n                <\/div>\n                \n                <div class=\"field-group full-width\">\n                    <label class=\"checkbox-label\">\n                        <input type=\"checkbox\" id=\"terms_agreement\" name=\"terms_agreement\" required>\n                        <span class=\"required\">*<\/span> I have read and agree to the Terms & Conditions\n                    <\/label>\n                <\/div>\n            <\/div>\n        <\/div>\n                            <div class=\"step-navigation\">\n                        <button type=\"button\" class=\"btn btn-secondary\" data-action=\"prev\">Back<\/button>\n                        <button type=\"button\" class=\"btn btn-primary\" data-action=\"next\">Continue<\/button>\n                    <\/div>\n                <\/div>\n                \n                <!-- Step 3: Disclaimer and Indemnity Form -->\n                <div class=\"form-step\" data-step-key=\"disclaimer_indemnity\" style=\"display: none;\">\n                            <div class=\"disclaimer-indemnity-section\">\n            <h3>Disclaimer and Indemnity Form<\/h3>\n            <div class=\"disclaimer-content\">\n                <div class=\"disclaimer-text\">\n                    I hereby acknowledge that undertaking an underwater dive is considered a high-risk activity\r\n\r\nI accept I have been made fully aware of and confirm that I fully understand the dangers and risks involved in underwater diving\r\n(including but not limited to the the medical risks and risks associated with underwater diving at Deep Sea World with potentially dangerous animals).\r\nIn particular, I acknowledge that animal behaviour can be unpredictable. I hereby confirm that, unless where Deep Sea World negligent, I will not hold Deep Sea World,\r\nand any company within the same group of companies and any of their representatives responsible for any liability, expense, loss,\r\nclaim, damage or injury howsoever caused suffered by me which may occur as a result of my participation in underwater diving at Deep Sea World.\r\n\r\nI acknowledge that I have received pre-diving briefings and confirm that I have read and fully understand all\r\nthe instructions relating to the dive, the conduct requirements of the dive and the dive plan details.\r\nI confirm that I have provided all information requested by Deep Sea World and that all such information provided is complete, accurate and not misleading.\r\n\r\nI agree that should I for any reason, deviate from the instructions relating to the dive, the conduct requirement of the dive and\/or from the dive plan,\r\nor if I have failed to provide all requested information or have provided incomplete, incorrect or misleading information, Deep Sea World may abort the dive without refund of monies to me.\r\nI agree to indemnify Deep Sea World, any other company within the same group of companies and all of their representatives from all liabilities, expenses, losses,\r\nclaims or damages suffered by all or any of them as a result of any such deviation, failure to provide be me.\r\n\r\nI acknowledge that the decision of Deep Sea World whether or not to allow me to participate in an underwater dive at Deep Sea World final.\r\n\r\nI also acknowledge that this disclaimer and indemnity does not affect my statutory or other legal rights.                <\/div>\n            <\/div>\n            \n            <div class=\"form-fields-grid\">\n                <div class=\"field-group\">\n                    <label for=\"disclaimer_full_name\">Full Name <span class=\"required\">*<\/span><\/label>\n                    <input type=\"text\" id=\"disclaimer_full_name\" name=\"disclaimer_full_name\" required>\n                <\/div>\n                \n                <div class=\"field-group full-width\">\n                    <label for=\"disclaimer_address\">Address <span class=\"required\">*<\/span><\/label>\n                    <textarea id=\"disclaimer_address\" name=\"disclaimer_address\" rows=\"3\" required><\/textarea>\n                <\/div>\n                \n                <div class=\"field-group\">\n                    <label for=\"disclaimer_signature\">Signature <span class=\"required\">*<\/span><\/label>\n                    <input type=\"text\" id=\"disclaimer_signature\" name=\"disclaimer_signature\" required>\n                <\/div>\n                \n                <div class=\"field-group\">\n                    <label for=\"disclaimer_date\">Date <span class=\"required\">*<\/span><\/label>\n                    <input type=\"date\" id=\"disclaimer_date\" name=\"disclaimer_date\" required value=\"2026-04-16\">\n                <\/div>\n                \n                <div class=\"field-group full-width\">\n                    <label class=\"checkbox-label\">\n                        <input type=\"checkbox\" id=\"disclaimer_agreement\" name=\"disclaimer_agreement\" required>\n                        <span class=\"required\">*<\/span> I have read and agree to the Disclaimer and Indemnity\n                    <\/label>\n                <\/div>\n            <\/div>\n        <\/div>\n                            <div class=\"step-navigation\">\n                        <button type=\"button\" class=\"btn btn-secondary\" data-action=\"prev\">Back<\/button>\n                        <button type=\"button\" class=\"btn btn-primary\" data-action=\"next\">Continue<\/button>\n                    <\/div>\n                <\/div>\n                \n                <!-- Step 4: Medical Questionnaire -->\n                <div class=\"form-step\" data-step-key=\"medical_questionnaire\" style=\"display: none;\">\n                            <div class=\"medical-questionnaire-section\">\n            <p>Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving fitness not represented on this form, consult with your physician before diving. If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and\/ or dive activities. References to \u201cdiving\u201d on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.<\/p>\n            <br\/>\n            <h3>Complete this questionnaire as a prerequisite to a recreational scuba diving or freediving course.<\/h3>\n            <p><strong>Note to reviewers:<\/strong> If you are uncertain or attempting to become pregnant, do not dive.<\/p>\n            \n            <div class=\"medical-questions\">\n                                    <div class=\"question-item\" data-question=\"q1\">\n                        <div class=\"question-header\">\n                            <span class=\"question-number\">1<\/span>\n                            <span class=\"question-text\">I have had problems with my lungs, breathing, heart, blood, or have been diagnosed with COVID-19.<\/span>\n                            <div class=\"toggle-switch\">\n                                <input type=\"radio\" name=\"q1\" value=\"no\" id=\"q1_no\" class=\"toggle-input\" required>\n                                <input type=\"radio\" name=\"q1\" value=\"yes\" id=\"q1_yes\" class=\"toggle-input\" required>\n                                <label for=\"q1_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                <label for=\"q1_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                <span class=\"toggle-slider\"><\/span>\n                            <\/div>\n                        <\/div>\n                        \n                                                    <div class=\"conditional-accordion\" data-box=\"A\" style=\"display: none;\">\n                                <div class=\"accordion-content\">\n                                    <h4>I have\/have had:<\/h4>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">Chest surgery, heart surgery, heart valve surgery, stent placement, or a pneumothorax (collapsed lung).<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_A_a1\" value=\"no\" id=\"box_A_a1_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_A_a1\" value=\"yes\" id=\"box_A_a1_yes\" class=\"toggle-input\">\n                                                <label for=\"box_A_a1_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_A_a1_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity\/exercise.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_A_a2\" value=\"no\" id=\"box_A_a2_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_A_a2\" value=\"yes\" id=\"box_A_a2_yes\" class=\"toggle-input\">\n                                                <label for=\"box_A_a2_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_A_a2_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_A_a3\" value=\"no\" id=\"box_A_a3_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_A_a3\" value=\"yes\" id=\"box_A_a3_yes\" class=\"toggle-input\">\n                                                <label for=\"box_A_a3_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_A_a3_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_A_a4\" value=\"no\" id=\"box_A_a4_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_A_a4\" value=\"yes\" id=\"box_A_a4_yes\" class=\"toggle-input\">\n                                                <label for=\"box_A_a4_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_A_a4_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">A diagnosis of COVID-19.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_A_a5\" value=\"no\" id=\"box_A_a5_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_A_a5\" value=\"yes\" id=\"box_A_a5_yes\" class=\"toggle-input\">\n                                                <label for=\"box_A_a5_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_A_a5_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                    <\/div>\n                            <\/div>\n                                            <\/div>\n                                                        <div class=\"question-item\" data-question=\"q2\">\n                        <div class=\"question-header\">\n                            <span class=\"question-number\">2<\/span>\n                            <span class=\"question-text\">I am over 45 years of age.<\/span>\n                            <div class=\"toggle-switch\">\n                                <input type=\"radio\" name=\"q2\" value=\"no\" id=\"q2_no\" class=\"toggle-input\" required>\n                                <input type=\"radio\" name=\"q2\" value=\"yes\" id=\"q2_yes\" class=\"toggle-input\" required>\n                                <label for=\"q2_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                <label for=\"q2_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                <span class=\"toggle-slider\"><\/span>\n                            <\/div>\n                        <\/div>\n                        \n                                                    <div class=\"conditional-accordion\" data-box=\"B\" style=\"display: none;\">\n                                <div class=\"accordion-content\">\n                                    <h4>I am over 45 years of age AND:<\/h4>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">I currently smoke or inhale nicotine by other means.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_B_b1\" value=\"no\" id=\"box_B_b1_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_B_b1\" value=\"yes\" id=\"box_B_b1_yes\" class=\"toggle-input\">\n                                                <label for=\"box_B_b1_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_B_b1_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">I have a high cholesterol level.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_B_b2\" value=\"no\" id=\"box_B_b2_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_B_b2\" value=\"yes\" id=\"box_B_b2_yes\" class=\"toggle-input\">\n                                                <label for=\"box_B_b2_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_B_b2_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">I have high blood pressure.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_B_b3\" value=\"no\" id=\"box_B_b3_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_B_b3\" value=\"yes\" id=\"box_B_b3_yes\" class=\"toggle-input\">\n                                                <label for=\"box_B_b3_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_B_b3_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_B_b4\" value=\"no\" id=\"box_B_b4_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_B_b4\" value=\"yes\" id=\"box_B_b4_yes\" class=\"toggle-input\">\n                                                <label for=\"box_B_b4_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_B_b4_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                    <\/div>\n                            <\/div>\n                                            <\/div>\n                                                        <div class=\"question-item\" data-question=\"q3\">\n                        <div class=\"question-header\">\n                            <span class=\"question-number\">3<\/span>\n                            <span class=\"question-text\">I struggle to perform moderate exercise OR have been unable to participate in normal physical activity in the past 12 months.<\/span>\n                            <div class=\"toggle-switch\">\n                                <input type=\"radio\" name=\"q3\" value=\"no\" id=\"q3_no\" class=\"toggle-input\" required>\n                                <input type=\"radio\" name=\"q3\" value=\"yes\" id=\"q3_yes\" class=\"toggle-input\" required>\n                                <label for=\"q3_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                <label for=\"q3_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                <span class=\"toggle-slider\"><\/span>\n                            <\/div>\n                        <\/div>\n                        \n                                            <\/div>\n                                                        <div class=\"question-item\" data-question=\"q4\">\n                        <div class=\"question-header\">\n                            <span class=\"question-number\">4<\/span>\n                            <span class=\"question-text\">I have had problems with my eyes, ears, or nasal passages\/sinuses.<\/span>\n                            <div class=\"toggle-switch\">\n                                <input type=\"radio\" name=\"q4\" value=\"no\" id=\"q4_no\" class=\"toggle-input\" required>\n                                <input type=\"radio\" name=\"q4\" value=\"yes\" id=\"q4_yes\" class=\"toggle-input\" required>\n                                <label for=\"q4_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                <label for=\"q4_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                <span class=\"toggle-slider\"><\/span>\n                            <\/div>\n                        <\/div>\n                        \n                                                    <div class=\"conditional-accordion\" data-box=\"C\" style=\"display: none;\">\n                                <div class=\"accordion-content\">\n                                    <h4>I have\/have had:<\/h4>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">Sinus surgery within the last 6 months.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_C_c1\" value=\"no\" id=\"box_C_c1_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_C_c1\" value=\"yes\" id=\"box_C_c1_yes\" class=\"toggle-input\">\n                                                <label for=\"box_C_c1_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_C_c1_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">Ear disease or ear surgery, hearing loss, or problems with balance.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_C_c2\" value=\"no\" id=\"box_C_c2_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_C_c2\" value=\"yes\" id=\"box_C_c2_yes\" class=\"toggle-input\">\n                                                <label for=\"box_C_c2_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_C_c2_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">Recurrent sinusitis within the past 12 months.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_C_c3\" value=\"no\" id=\"box_C_c3_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_C_c3\" value=\"yes\" id=\"box_C_c3_yes\" class=\"toggle-input\">\n                                                <label for=\"box_C_c3_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_C_c3_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">Eye surgery within the past 3 months.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_C_c4\" value=\"no\" id=\"box_C_c4_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_C_c4\" value=\"yes\" id=\"box_C_c4_yes\" class=\"toggle-input\">\n                                                <label for=\"box_C_c4_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_C_c4_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                    <\/div>\n                            <\/div>\n                                            <\/div>\n                                                        <div class=\"question-item\" data-question=\"q5\">\n                        <div class=\"question-header\">\n                            <span class=\"question-number\">5<\/span>\n                            <span class=\"question-text\">I have had surgery within the last 12 months, OR have ongoing problems related to past surgery.<\/span>\n                            <div class=\"toggle-switch\">\n                                <input type=\"radio\" name=\"q5\" value=\"no\" id=\"q5_no\" class=\"toggle-input\" required>\n                                <input type=\"radio\" name=\"q5\" value=\"yes\" id=\"q5_yes\" class=\"toggle-input\" required>\n                                <label for=\"q5_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                <label for=\"q5_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                <span class=\"toggle-slider\"><\/span>\n                            <\/div>\n                        <\/div>\n                        \n                                            <\/div>\n                                                        <div class=\"question-item\" data-question=\"q6\">\n                        <div class=\"question-header\">\n                            <span class=\"question-number\">6<\/span>\n                            <span class=\"question-text\">I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or neurologic disease.<\/span>\n                            <div class=\"toggle-switch\">\n                                <input type=\"radio\" name=\"q6\" value=\"no\" id=\"q6_no\" class=\"toggle-input\" required>\n                                <input type=\"radio\" name=\"q6\" value=\"yes\" id=\"q6_yes\" class=\"toggle-input\" required>\n                                <label for=\"q6_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                <label for=\"q6_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                <span class=\"toggle-slider\"><\/span>\n                            <\/div>\n                        <\/div>\n                        \n                                                    <div class=\"conditional-accordion\" data-box=\"D\" style=\"display: none;\">\n                                <div class=\"accordion-content\">\n                                    <h4>I have\/have had:<\/h4>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">Head injury with loss of consciousness within the past 5 years.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_D_d1\" value=\"no\" id=\"box_D_d1_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_D_d1\" value=\"yes\" id=\"box_D_d1_yes\" class=\"toggle-input\">\n                                                <label for=\"box_D_d1_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_D_d1_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">Persistent neurologic injury or disease.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_D_d2\" value=\"no\" id=\"box_D_d2_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_D_d2\" value=\"yes\" id=\"box_D_d2_yes\" class=\"toggle-input\">\n                                                <label for=\"box_D_d2_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_D_d2_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">Recurring migraine headaches within the past 12 months, or take medications to prevent them.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_D_d3\" value=\"no\" id=\"box_D_d3_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_D_d3\" value=\"yes\" id=\"box_D_d3_yes\" class=\"toggle-input\">\n                                                <label for=\"box_D_d3_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_D_d3_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">Blackouts or fainting (full\/partial loss of consciousness) within the last 5 years.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_D_d4\" value=\"no\" id=\"box_D_d4_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_D_d4\" value=\"yes\" id=\"box_D_d4_yes\" class=\"toggle-input\">\n                                                <label for=\"box_D_d4_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_D_d4_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">Epilepsy, seizures, or convulsions, OR take medications to prevent them.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_D_d5\" value=\"no\" id=\"box_D_d5_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_D_d5\" value=\"yes\" id=\"box_D_d5_yes\" class=\"toggle-input\">\n                                                <label for=\"box_D_d5_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_D_d5_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                    <\/div>\n                            <\/div>\n                                            <\/div>\n                                                        <div class=\"question-item\" data-question=\"q7\">\n                        <div class=\"question-header\">\n                            <span class=\"question-number\">7<\/span>\n                            <span class=\"question-text\">I am undergoing treatment for psychological problems, panic attacks, or addiction; or have a learning disability.<\/span>\n                            <div class=\"toggle-switch\">\n                                <input type=\"radio\" name=\"q7\" value=\"no\" id=\"q7_no\" class=\"toggle-input\" required>\n                                <input type=\"radio\" name=\"q7\" value=\"yes\" id=\"q7_yes\" class=\"toggle-input\" required>\n                                <label for=\"q7_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                <label for=\"q7_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                <span class=\"toggle-slider\"><\/span>\n                            <\/div>\n                        <\/div>\n                        \n                                                    <div class=\"conditional-accordion\" data-box=\"E\" style=\"display: none;\">\n                                <div class=\"accordion-content\">\n                                    <h4>I have\/have had:<\/h4>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">Behavioral health, mental or psychological problems requiring medical\/psychiatric treatment.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_E_e1\" value=\"no\" id=\"box_E_e1_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_E_e1\" value=\"yes\" id=\"box_E_e1_yes\" class=\"toggle-input\">\n                                                <label for=\"box_E_e1_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_E_e1_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_E_e2\" value=\"no\" id=\"box_E_e2_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_E_e2\" value=\"yes\" id=\"box_E_e2_yes\" class=\"toggle-input\">\n                                                <label for=\"box_E_e2_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_E_e2_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">Been diagnosed with a mental health condition or learning disorder that requires ongoing care.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_E_e3\" value=\"no\" id=\"box_E_e3_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_E_e3\" value=\"yes\" id=\"box_E_e3_yes\" class=\"toggle-input\">\n                                                <label for=\"box_E_e3_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_E_e3_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">An addiction to drugs or alcohol requiring treatment within the last 5 years.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_E_e4\" value=\"no\" id=\"box_E_e4_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_E_e4\" value=\"yes\" id=\"box_E_e4_yes\" class=\"toggle-input\">\n                                                <label for=\"box_E_e4_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_E_e4_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                    <\/div>\n                            <\/div>\n                                            <\/div>\n                                                        <div class=\"question-item\" data-question=\"q8\">\n                        <div class=\"question-header\">\n                            <span class=\"question-number\">8<\/span>\n                            <span class=\"question-text\">I have had back problems, hernia, ulcers, or diabetes.<\/span>\n                            <div class=\"toggle-switch\">\n                                <input type=\"radio\" name=\"q8\" value=\"no\" id=\"q8_no\" class=\"toggle-input\" required>\n                                <input type=\"radio\" name=\"q8\" value=\"yes\" id=\"q8_yes\" class=\"toggle-input\" required>\n                                <label for=\"q8_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                <label for=\"q8_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                <span class=\"toggle-slider\"><\/span>\n                            <\/div>\n                        <\/div>\n                        \n                                                    <div class=\"conditional-accordion\" data-box=\"F\" style=\"display: none;\">\n                                <div class=\"accordion-content\">\n                                    <h4>I have\/have had:<\/h4>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">Recurrent back problems in the last 6 months that limit my everyday activity.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_F_f1\" value=\"no\" id=\"box_F_f1_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_F_f1\" value=\"yes\" id=\"box_F_f1_yes\" class=\"toggle-input\">\n                                                <label for=\"box_F_f1_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_F_f1_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">Back or spinal surgery within the last 12 months.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_F_f2\" value=\"no\" id=\"box_F_f2_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_F_f2\" value=\"yes\" id=\"box_F_f2_yes\" class=\"toggle-input\">\n                                                <label for=\"box_F_f2_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_F_f2_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">Diabetes, drug- or diet-controlled, OR gestational diabetes within the last 12 months.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_F_f3\" value=\"no\" id=\"box_F_f3_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_F_f3\" value=\"yes\" id=\"box_F_f3_yes\" class=\"toggle-input\">\n                                                <label for=\"box_F_f3_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_F_f3_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">An uncorrected hernia that limits my physical abilities.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_F_f4\" value=\"no\" id=\"box_F_f4_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_F_f4\" value=\"yes\" id=\"box_F_f4_yes\" class=\"toggle-input\">\n                                                <label for=\"box_F_f4_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_F_f4_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_F_f5\" value=\"no\" id=\"box_F_f5_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_F_f5\" value=\"yes\" id=\"box_F_f5_yes\" class=\"toggle-input\">\n                                                <label for=\"box_F_f5_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_F_f5_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                    <\/div>\n                            <\/div>\n                                            <\/div>\n                                                        <div class=\"question-item\" data-question=\"q9\">\n                        <div class=\"question-header\">\n                            <span class=\"question-number\">9<\/span>\n                            <span class=\"question-text\">I have had stomach or intestine problems, including recent diarrhea.<\/span>\n                            <div class=\"toggle-switch\">\n                                <input type=\"radio\" name=\"q9\" value=\"no\" id=\"q9_no\" class=\"toggle-input\" required>\n                                <input type=\"radio\" name=\"q9\" value=\"yes\" id=\"q9_yes\" class=\"toggle-input\" required>\n                                <label for=\"q9_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                <label for=\"q9_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                <span class=\"toggle-slider\"><\/span>\n                            <\/div>\n                        <\/div>\n                        \n                                                    <div class=\"conditional-accordion\" data-box=\"G\" style=\"display: none;\">\n                                <div class=\"accordion-content\">\n                                    <h4>I have had:<\/h4>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">Ostomy surgery and do not have medical clearance to swim or engage in physical activity.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_G_g1\" value=\"no\" id=\"box_G_g1_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_G_g1\" value=\"yes\" id=\"box_G_g1_yes\" class=\"toggle-input\">\n                                                <label for=\"box_G_g1_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_G_g1_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">Dehydration requiring medical intervention within the last 7 days.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_G_g2\" value=\"no\" id=\"box_G_g2_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_G_g2\" value=\"yes\" id=\"box_G_g2_yes\" class=\"toggle-input\">\n                                                <label for=\"box_G_g2_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_G_g2_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_G_g3\" value=\"no\" id=\"box_G_g3_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_G_g3\" value=\"yes\" id=\"box_G_g3_yes\" class=\"toggle-input\">\n                                                <label for=\"box_G_g3_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_G_g3_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_G_g4\" value=\"no\" id=\"box_G_g4_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_G_g4\" value=\"yes\" id=\"box_G_g4_yes\" class=\"toggle-input\">\n                                                <label for=\"box_G_g4_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_G_g4_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">Active or uncontrolled ulcerative colitis or Crohn&#039;s disease.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_G_g5\" value=\"no\" id=\"box_G_g5_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_G_g5\" value=\"yes\" id=\"box_G_g5_yes\" class=\"toggle-input\">\n                                                <label for=\"box_G_g5_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_G_g5_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                            <div class=\"sub-question\">\n                                            <span class=\"sub-question-text\">Bariatric surgery within the last 12 months.<\/span>\n                                            <div class=\"toggle-switch small\">\n                                                <input type=\"radio\" name=\"box_G_g6\" value=\"no\" id=\"box_G_g6_no\" class=\"toggle-input\">\n                                                <input type=\"radio\" name=\"box_G_g6\" value=\"yes\" id=\"box_G_g6_yes\" class=\"toggle-input\">\n                                                <label for=\"box_G_g6_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                                <label for=\"box_G_g6_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                                <span class=\"toggle-slider\"><\/span>\n                                            <\/div>\n                                        <\/div>\n                                                                    <\/div>\n                            <\/div>\n                                            <\/div>\n                                                        <div class=\"question-item\" data-question=\"q10\">\n                        <div class=\"question-header\">\n                            <span class=\"question-number\">10<\/span>\n                            <span class=\"question-text\">I am taking prescription medications (except birth control or anti-malarial drugs).<\/span>\n                            <div class=\"toggle-switch\">\n                                <input type=\"radio\" name=\"q10\" value=\"no\" id=\"q10_no\" class=\"toggle-input\" required>\n                                <input type=\"radio\" name=\"q10\" value=\"yes\" id=\"q10_yes\" class=\"toggle-input\" required>\n                                <label for=\"q10_no\" class=\"toggle-label toggle-no\">No<\/label>\n                                <label for=\"q10_yes\" class=\"toggle-label toggle-yes\">Yes<\/label>\n                                <span class=\"toggle-slider\"><\/span>\n                            <\/div>\n                        <\/div>\n                        \n                                            <\/div>\n                                                <\/div>\n        <\/div>\n                            <div class=\"step-navigation\">\n                        <button type=\"button\" class=\"btn btn-secondary\" data-action=\"prev\">Back<\/button>\n                        <button type=\"button\" class=\"btn btn-primary\" data-action=\"next\">Continue<\/button>\n                    <\/div>\n                <\/div>\n                \n                <!-- Step 5: Medical Evaluation Response -->\n                <div class=\"form-step\" data-step-key=\"medical_evaluation\" style=\"display: none;\">\n                            <div class=\"medical-evaluation-section\">\n            <div id=\"physician-required-section\" style=\"display: none;\">\n                <div class=\"info-box blue\">\n                    <h3>A medical evaluation is required<\/h3>\n                    <p>Based on your answers on the previous page, a medical evaluation by a physician is required.<\/p>\n                    <p><strong>Instructions:<\/strong> Please click the link below to download the diver medical form and take all three pages of this form (Participant Questionnaire and the Physician's Evaluation Form) to your physician for a medical evaluation. Participation in a diving course requires your physician's approval.<\/p>\n                    <button type=\"button\" id=\"download-physician-form\" class=\"btn btn-download\">Download PDF<\/button>\n                <\/div>\n            <\/div>\n            \n            <div id=\"no-physician-required-section\" style=\"display: none;\">\n                <div class=\"info-box green\">\n                    <h3>A medical evaluation is not required<\/h3>\n                    <p>Please read and agree to the participant statement below by signing and dating it.<\/p>\n                <\/div>\n                \n                <div class=\"participant-statement-box\">\n                    <h4>Participant Statement<\/h4>\n                    <p><strong>\"I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.\"<\/strong><\/p>\n                    \n                    <div class=\"form-fields-grid\">\n                        <div class=\"field-group\">\n                            <label for=\"eval_participant_name\">Participant Name <span class=\"required\">*<\/span><\/label>\n                            <input type=\"text\" id=\"eval_participant_name\" name=\"eval_participant_name\" required readonly>\n                        <\/div>\n                        \n                        <div class=\"field-group\">\n                            <label for=\"eval_date_of_birth\">Date of Birth <span class=\"required\">*<\/span><\/label>\n                            <input type=\"date\" id=\"eval_date_of_birth\" name=\"eval_date_of_birth\" required readonly>\n                        <\/div>\n                        \n                        <div class=\"field-group\">\n                            <label for=\"eval_participant_signature\">Participant Signature <span class=\"required\">*<\/span><\/label>\n                            <input type=\"text\" id=\"eval_participant_signature\" name=\"eval_participant_signature\" required>\n                        <\/div>\n                        \n                        <div class=\"field-group\">\n                            <label for=\"eval_signature_date\">Date <span class=\"required\">*<\/span><\/label>\n                            <input type=\"date\" id=\"eval_signature_date\" name=\"eval_signature_date\" required value=\"2026-04-16\">\n                        <\/div>\n                        \n                        <div class=\"field-group full-width minor-note conditional-minor-note\" style=\"display: none;\">\n                            <p><em>Note: If participant is a minor, parent\/guardian signature required<\/em><\/p>\n                        <\/div>\n\n                        \n                                            <\/div>\n                <\/div>\n            <\/div>\n        <\/div>\n                            <div class=\"step-navigation\">\n                        <button type=\"button\" class=\"btn btn-secondary\" data-action=\"prev\">Back<\/button>\n                                                    <button type=\"button\" class=\"btn btn-primary\" data-action=\"next\">Continue<\/button>\n                                            <\/div>\n                <\/div>\n                \n                                    <!-- Step 6: Equipment Selection (Qualified only) -->\n                    <div class=\"form-step\" data-step-key=\"equipment\" style=\"display: none;\">\n                                <div class=\"equipment-selection\">\n            <p>Select the equipment you would like to rent for your diving experience:<\/p>\n            \n            <div class=\"equipment-grid\">\n                                    <div class=\"equipment-item\">\n                        <label class=\"equipment-label\">\n                            <input type=\"checkbox\" \n                                   name=\"equipment[]\" \n                                   value=\"1\" \n                                   data-price=\"35\" \/>\n                            <div class=\"equipment-info\">\n                                <span class=\"equipment-name\">Complete Dive Set<\/span>\n                                <span class=\"equipment-price\">\u00a335.00<\/span>\n                            <\/div>\n                        <\/label>\n                    <\/div>\n                                    <div class=\"equipment-item\">\n                        <label class=\"equipment-label\">\n                            <input type=\"checkbox\" \n                                   name=\"equipment[]\" \n                                   value=\"2\" \n                                   data-price=\"12.5\" \/>\n                            <div class=\"equipment-info\">\n                                <span class=\"equipment-name\">BCD<\/span>\n                                <span class=\"equipment-price\">\u00a312.50<\/span>\n                            <\/div>\n                        <\/label>\n                    <\/div>\n                                    <div class=\"equipment-item\">\n                        <label class=\"equipment-label\">\n                            <input type=\"checkbox\" \n                                   name=\"equipment[]\" \n                                   value=\"3\" \n                                   data-price=\"7.5\" \/>\n                            <div class=\"equipment-info\">\n                                <span class=\"equipment-name\">Cylinder<\/span>\n                                <span class=\"equipment-price\">\u00a37.50<\/span>\n                            <\/div>\n                        <\/label>\n                    <\/div>\n                                    <div class=\"equipment-item\">\n                        <label class=\"equipment-label\">\n                            <input type=\"checkbox\" \n                                   name=\"equipment[]\" \n                                   value=\"4\" \n                                   data-price=\"2.5\" \/>\n                            <div class=\"equipment-info\">\n                                <span class=\"equipment-name\">Mask<\/span>\n                                <span class=\"equipment-price\">\u00a32.50<\/span>\n                            <\/div>\n                        <\/label>\n                    <\/div>\n                                    <div class=\"equipment-item\">\n                        <label class=\"equipment-label\">\n                            <input type=\"checkbox\" \n                                   name=\"equipment[]\" \n                                   value=\"5\" \n                                   data-price=\"12.5\" \/>\n                            <div class=\"equipment-info\">\n                                <span class=\"equipment-name\">Regulator<\/span>\n                                <span class=\"equipment-price\">\u00a312.50<\/span>\n                            <\/div>\n                        <\/label>\n                    <\/div>\n                                    <div class=\"equipment-item\">\n                        <label class=\"equipment-label\">\n                            <input type=\"checkbox\" \n                                   name=\"equipment[]\" \n                                   value=\"6\" \n                                   data-price=\"5\" \/>\n                            <div class=\"equipment-info\">\n                                <span class=\"equipment-name\">Weight Belt<\/span>\n                                <span class=\"equipment-price\">\u00a35.00<\/span>\n                            <\/div>\n                        <\/label>\n                    <\/div>\n                                    <div class=\"equipment-item\">\n                        <label class=\"equipment-label\">\n                            <input type=\"checkbox\" \n                                   name=\"equipment[]\" \n                                   value=\"7\" \n                                   data-price=\"5\" \/>\n                            <div class=\"equipment-info\">\n                                <span class=\"equipment-name\">Wet\/Drysuit<\/span>\n                                <span class=\"equipment-price\">\u00a35.00<\/span>\n                            <\/div>\n                        <\/label>\n                    <\/div>\n                            <\/div>\n            \n            <div class=\"equipment-total\">\n                <strong>Total: <span id=\"equipment-total-amount\">\u00a30.00<\/span><\/strong>\n            <\/div>\n        <\/div>\n                                <div class=\"step-navigation\">\n                            <button type=\"button\" class=\"btn btn-secondary\" data-action=\"prev\">Back<\/button>\n                            <button type=\"button\" class=\"btn btn-primary\" data-action=\"next\">Continue<\/button>\n                        <\/div>\n                    <\/div>\n                    \n                    <!-- Step 7: Summary and Submit (Qualified only) -->\n                    <div class=\"form-step\" data-step-key=\"summary\" style=\"display: none;\">\n                                <div class=\"form-summary\">\n            <h3>Review Your Information<\/h3>\n            \n            <div class=\"summary-section\">\n                <h4>Personal Information<\/h4>\n                <div id=\"summary-personal\"><\/div>\n            <\/div>\n            \n            <div class=\"summary-section\">\n                <h4>Medical Status<\/h4>\n                <div id=\"summary-medical\"><\/div>\n            <\/div>\n            \n            <div class=\"summary-section\" id=\"summary-equipment-card\" style=\"display:none;\">\n                <h4>Equipment Rental<\/h4>\n                <div id=\"summary-equipment\"><\/div>\n            <\/div>\n            \n            <div class=\"summary-confirmation\">\n                <p><strong>Please review all information carefully before submitting.<\/strong><\/p>\n            <\/div>\n        <\/div>\n                                <div class=\"step-navigation\">\n                            <button type=\"button\" class=\"btn btn-secondary\" data-action=\"prev\">Back<\/button>\n                            <button type=\"button\" class=\"btn btn-primary\" data-action=\"submit\">Submit<\/button>\n                        <\/div>\n                    <\/div>\n                            <\/form>\n        <\/div>\n        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