{"id":12290,"date":"2023-09-15T13:47:42","date_gmt":"2023-09-15T11:47:42","guid":{"rendered":"https:\/\/balancebelt.net\/?page_id=12290"},"modified":"2025-08-26T19:29:56","modified_gmt":"2025-08-26T17:29:56","slug":"do-the-test","status":"publish","type":"page","link":"https:\/\/balancebelt.net\/en\/do-the-test\/","title":{"rendered":"Do the Test"},"content":{"rendered":"\n\t\t<div id=\"fws_6a326532987ea\"  data-column-margin=\"default\" data-midnight=\"dark\"  class=\"wpb_row vc_row-fluid vc_row\"  style=\"padding-top: 0px; padding-bottom: 0px; \"><div class=\"row-bg-wrap\" data-bg-animation=\"none\" data-bg-animation-delay=\"\" data-bg-overlay=\"false\"><div class=\"inner-wrap row-bg-layer\" ><div class=\"row-bg viewport-desktop\"  style=\"\"><\/div><\/div><\/div><div class=\"row_col_wrap_12 col span_12 dark left\">\n\t<div  class=\"vc_col-sm-12 wpb_column column_container vc_column_container col no-extra-padding inherit_tablet inherit_phone \"  data-padding-pos=\"all\" data-has-bg-color=\"false\" data-bg-color=\"\" data-bg-opacity=\"1\" data-animation=\"\" data-delay=\"0\" >\n\t\t<div class=\"vc_column-inner\" >\n\t\t\t<div class=\"wpb_wrapper\">\n\t\t\t\t\n<div class=\"wpb_text_column wpb_content_element \" >\n\t<div class=\"wpb_wrapper\">\n\t\t<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\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_9' style='display:none'><div id='gf_9' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">BalanceBelt Test<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_9'  action='\/en\/wp-json\/wp\/v2\/pages\/12290#gf_9' data-formid='9' novalidate><div id='gf_page_steps_9' class='gf_page_steps'><div id='gf_step_9_1' class='gf_step gf_step_active gf_step_first'><span class='gf_step_number'>1<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_9_2' class='gf_step gf_step_next gf_step_pending'><span class='gf_step_number'>2<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_9_3' class='gf_step gf_step_pending'><span class='gf_step_number'>3<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_9_4' class='gf_step gf_step_pending'><span class='gf_step_number'>4<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_9_5' class='gf_step gf_step_pending'><span class='gf_step_number'>5<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_9_6' class='gf_step gf_step_pending'><span class='gf_step_number'>6<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_9_7' class='gf_step gf_step_pending'><span class='gf_step_number'>7<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_9_8' class='gf_step gf_step_pending'><span class='gf_step_number'>8<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_9_9' class='gf_step gf_step_pending'><span class='gf_step_number'>9<\/span><span class='gf_step_label'><\/span><\/div><div id='gf_step_9_10' class='gf_step gf_step_last gf_step_pending'><span class='gf_step_number'>10<\/span><span class='gf_step_label'><\/span><\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_9_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_9' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_9_53\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><H2>Take the test to see if the BalanceBelt could help you regain your balance.<\/H2>\n<p>\n\n<br>\nThis short test helps us find out if the BalanceBelt can improve your balance and mobility. If the test shows it might help, we\u2019ll put you in touch with a specialist for further support. It takes about 5 minutes to complete the test.\n<\/p>\n<br><br><\/div><fieldset id=\"field_9_47\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Question 1<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_9_47'>On the first question, score your balance on a 1 - 10 scale, where 10 is the best balance you have had during your lifetime and 0 is no balance at all.\n<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_9_47'><div class='gchoice gchoice_9_47_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.1' type='checkbox'  value='If I would grade my balance it would be 5 or lower.'  id='choice_9_47_1'   aria-describedby=\"gfield_description_9_47\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_47_1' id='label_9_47_1' class='gform-field-label gform-field-label--type-inline'>If I would grade my balance it would be 5 or lower.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_47_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.2' type='checkbox'  value='I am diagnosed with BVL, UVL or PPPD.'  id='choice_9_47_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_47_2' id='label_9_47_2' class='gform-field-label gform-field-label--type-inline'>I am diagnosed with BVL, UVL or PPPD.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_47_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.3' type='checkbox'  value='I do NOT have a neurologic condition like Parkinsons, Multiple Sclerosis, etc.'  id='choice_9_47_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_47_3' id='label_9_47_3' class='gform-field-label gform-field-label--type-inline'>I do NOT have a neurologic condition like Parkinsons, Multiple Sclerosis, etc.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_47_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.4' type='checkbox'  value='I did NOT have a stroke.'  id='choice_9_47_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_47_4' id='label_9_47_4' class='gform-field-label gform-field-label--type-inline'>I did NOT have a stroke.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_47_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.5' type='checkbox'  value='None of the above.'  id='choice_9_47_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_47_5' id='label_9_47_5' class='gform-field-label gform-field-label--type-inline'>None of the above.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_9_51' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_9_2' class='gform_page' data-js='page-field-id-51' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_9_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_9_50\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >Thank you for your interest in the BalanceBelt!\n<br><br>\nBased on the information you have provided, it appears that not all four conditions for optimal use of the BalanceBelt have been met. The four criteria that are important for the effective use of the BalanceBelt are:\nA balance score of 5 or lower on a scale of 1 to 10.\nDiagnosed with BVL, UVL, or PPPD.\nNo neurological conditions such as Parkinson's, Multiple Sclerosis, etc.\nNo previous stroke.\n<br><br>\nIf you have not yet had a diagnostic test for your dizziness, loss of balance, or poor mobility, we recommend contacting your GP for a referral to a Vestibular Specialist who can assess the cause of your symptoms. After a diagnostic assessment, you may fall within the group for whom the BalanceBelt can offer help.\n<br><br>\nThe BalanceBelt is specifically designed to help with balance problems resulting from conditions such as Unilateral Vestibular Lesion (UVL), Bilateral Vestibular Lesion (BVL), and Persistent Postural-Perceptual Dizziness (PPPD). These conditions affect the vestibular system and cause disruptions in how the brain perceives balance and spatial orientation. The BalanceBelt works by stimulating proprioception (the sense of body position) and restoring balance through targeted feedback via vibration, which is particularly effective for people with vestibular disorders such as UVL, BVL, and PPPD.\n<br><br>\nTo experience the effects of the BalanceBelt, your balance must be sufficiently impaired (a score of 5 or less on a scale of 1 to 10). Only then can the BalanceBelt provide the necessary stimuli to the brain to improve balance.\n<br><br>\nIn the case of neurological disorders such as Parkinson's or Multiple Sclerosis, or after a stroke, the causes of balance problems may be more complex and are often related to motor dysfunctions, muscle weakness, or coordination problems. The BalanceBelt has not always proven effective in conditions where balance is affected by factors other than just the vestibular system (e.g., by nervous system or brain). Therefore, BalanceBelt focuses primarily on vestibular disorders. \n<br><br>\nIf you do not fall within the group for whom the BalanceBelt can offer substantial assistance, there are still several other options to improve your balance. We kindly refer you to the frequently asked questions on our website, where we provide further guidance on alternative treatments.\n<\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_9_6' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='previous'  \/> <input type='button' id='gform_next_button_9_6' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_9_3' class='gform_page' data-js='page-field-id-6' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_9_3' class='gform_fields top_label form_sublabel_below description_above validation_below'><fieldset id=\"field_9_25\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >1. Do you use walking aids?<\/legend><div class='gfield_description' id='gfield_description_9_25'>(Select one or more)<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_9_25'><div class='gchoice gchoice_9_25_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.1' type='checkbox'  value='Crutches'  id='choice_9_25_1'   aria-describedby=\"gfield_description_9_25\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_25_1' id='label_9_25_1' class='gform-field-label gform-field-label--type-inline'>Crutches<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_25_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.2' type='checkbox'  value='Cane'  id='choice_9_25_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_25_2' id='label_9_25_2' class='gform-field-label gform-field-label--type-inline'>Cane<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_25_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.3' type='checkbox'  value='Walker frame'  id='choice_9_25_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_25_3' id='label_9_25_3' class='gform-field-label gform-field-label--type-inline'>Walker frame<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_25_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.4' type='checkbox'  value='Rollator'  id='choice_9_25_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_25_4' id='label_9_25_4' class='gform-field-label gform-field-label--type-inline'>Rollator<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_25_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.5' type='checkbox'  value='Wheel chair'  id='choice_9_25_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_25_5' id='label_9_25_5' class='gform-field-label gform-field-label--type-inline'>Wheel chair<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_25_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.6' type='checkbox'  value='I do not use walking aids'  id='choice_9_25_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_25_6' id='label_9_25_6' class='gform-field-label gform-field-label--type-inline'>I do not use walking aids<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_9_39' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='previous'  \/> <input type='button' id='gform_next_button_9_39' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_9_4' class='gform_page' data-js='page-field-id-39' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_9_4' class='gform_fields top_label form_sublabel_below description_above validation_below'><fieldset id=\"field_9_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2. How many times did you fall in the last 6 months?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_9'>\n\t\t\t<div class='gchoice gchoice_9_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='I did not fall'  id='choice_9_9_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_9_0' id='label_9_9_0' class='gform-field-label gform-field-label--type-inline'>I did not fall<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='I fell 1 - 2 times'  id='choice_9_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_9_1' id='label_9_9_1' class='gform-field-label gform-field-label--type-inline'>I fell 1 - 2 times<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_9_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='I fell 3 times or more'  id='choice_9_9_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_9_2' id='label_9_9_2' class='gform-field-label gform-field-label--type-inline'>I fell 3 times or more<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_9_8' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_9_8' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_9_5' class='gform_page' data-js='page-field-id-8' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_9_5' class='gform_fields top_label form_sublabel_below description_above validation_below'><fieldset id=\"field_9_7\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >3. Can you stand and\/or walk when somebody holds your hand?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_7'>\n\t\t\t<div class='gchoice gchoice_9_7_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='No.'  id='choice_9_7_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_7_0' id='label_9_7_0' class='gform-field-label gform-field-label--type-inline'>No.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_7_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='I can stand.'  id='choice_9_7_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_7_1' id='label_9_7_1' class='gform-field-label gform-field-label--type-inline'>I can stand.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_7_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='I can stand and walk.'  id='choice_9_7_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_7_2' id='label_9_7_2' class='gform-field-label gform-field-label--type-inline'>I can stand and walk.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_9_10' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_9_10' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_9_6' class='gform_page' data-js='page-field-id-10' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_9_6' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_9_27\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_27'>4. How would you rate your Balance and Mobility (1 - 10)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_9_27'><br>1 = <b>very bad<\/b>: I cannot stand\/walk without aids. <br>\n\n10 = <b>very good<\/b>:  Like when you were young.<\/div><div class='ginput_container ginput_container_select'><select name='input_27' id='input_9_27' class='large gfield_select'  aria-describedby=\"gfield_description_9_27\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Please choose a number' >Please choose a number<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><\/select><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_9_15' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_9_15' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_9_7' class='gform_page' data-js='page-field-id-15' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_9_7' class='gform_fields top_label form_sublabel_below description_above validation_below'><fieldset id=\"field_9_16\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >5. How is your vision?<\/legend><div class='gfield_description' id='gfield_description_9_16'>(Select one or more)<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_9_16'><div class='gchoice gchoice_9_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='I have blurred vision while walking.'  id='choice_9_16_1'   aria-describedby=\"gfield_description_9_16\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_16_1' id='label_9_16_1' class='gform-field-label gform-field-label--type-inline'>I have blurred vision while walking.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='I have blurred vision while travelling (train, car, etc.).'  id='choice_9_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_16_2' id='label_9_16_2' class='gform-field-label gform-field-label--type-inline'>I have blurred vision while travelling (train, car, etc.).<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_16_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.3' type='checkbox'  value='When walking, I have to stand still to recognise faces or to read (road) signs.'  id='choice_9_16_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_16_3' id='label_9_16_3' class='gform-field-label gform-field-label--type-inline'>When walking, I have to stand still to recognise faces or to read (road) signs.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_16_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.4' type='checkbox'  value='I have blurred vision while chewing on my food.'  id='choice_9_16_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_16_4' id='label_9_16_4' class='gform-field-label gform-field-label--type-inline'>I have blurred vision while chewing on my food.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_16_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.5' type='checkbox'  value='I have blurred vision when quickly turning my head.'  id='choice_9_16_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_16_5' id='label_9_16_5' class='gform-field-label gform-field-label--type-inline'>I have blurred vision when quickly turning my head.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_16_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.6' type='checkbox'  value='None of the above.'  id='choice_9_16_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_16_6' id='label_9_16_6' class='gform-field-label gform-field-label--type-inline'>None of the above.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_9_17' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_9_17' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_9_8' class='gform_page' data-js='page-field-id-17' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_9_8' class='gform_fields top_label form_sublabel_below description_above validation_below'><fieldset id=\"field_9_18\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >6. How is your Balance?<\/legend><div class='gfield_description' id='gfield_description_9_18'>Do you experience balance problems ...<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_9_18'><div class='gchoice gchoice_9_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='... when turning your head to the right or left when crossing the street.'  id='choice_9_18_1'   aria-describedby=\"gfield_description_9_18\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_9_18_1' id='label_9_18_1' class='gform-field-label gform-field-label--type-inline'>... when turning your head to the right or left when crossing the street.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_18_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.2' type='checkbox'  value='... when walking on uneven surfaces (like in the woods, beach, etc.).'  id='choice_9_18_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_18_2' id='label_9_18_2' class='gform-field-label gform-field-label--type-inline'>... when walking on uneven surfaces (like in the woods, beach, etc.).<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_18_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.3' type='checkbox'  value='... during daily activities.'  id='choice_9_18_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_18_3' id='label_9_18_3' class='gform-field-label gform-field-label--type-inline'>... during daily activities.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_18_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.4' type='checkbox'  value='... when walking in reduced light.'  id='choice_9_18_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_18_4' id='label_9_18_4' class='gform-field-label gform-field-label--type-inline'>... when walking in reduced light.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_18_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.5' type='checkbox'  value='... when walking, because you need to pay attention to the ground to avoid falling.'  id='choice_9_18_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_18_5' id='label_9_18_5' class='gform-field-label gform-field-label--type-inline'>... when walking, because you need to pay attention to the ground to avoid falling.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_18_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.6' type='checkbox'  value='None of the above.'  id='choice_9_18_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_18_6' id='label_9_18_6' class='gform-field-label gform-field-label--type-inline'>None of the above.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_9_19' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_9_19' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_9_9' class='gform_page' data-js='page-field-id-19' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_9_9' class='gform_fields top_label form_sublabel_below description_above validation_below'><fieldset id=\"field_9_35\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >7. What diagnosed condition do you have?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_9_35'><div class='gchoice gchoice_9_35_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.1' type='checkbox'  value='Bilateral Vestibular Hypofunction or Loss (BVH or BVL)'  id='choice_9_35_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_35_1' id='label_9_35_1' class='gform-field-label gform-field-label--type-inline'>Bilateral Vestibular Hypofunction or Loss (BVH or BVL)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_35_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.2' type='checkbox'  value='Unilateral Vestibular Hypofunction or Loss (UVH or UVL)'  id='choice_9_35_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_35_2' id='label_9_35_2' class='gform-field-label gform-field-label--type-inline'>Unilateral Vestibular Hypofunction or Loss (UVH or UVL)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_35_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.3' type='checkbox'  value='Persistent Postural-Perceptual Dizziness (PPPD)'  id='choice_9_35_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_35_3' id='label_9_35_3' class='gform-field-label gform-field-label--type-inline'>Persistent Postural-Perceptual Dizziness (PPPD)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_35_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.4' type='checkbox'  value='Other condition'  id='choice_9_35_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_35_4' id='label_9_35_4' class='gform-field-label gform-field-label--type-inline'>Other condition<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_38\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_38'>What other condition do you have?<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_9_38' type='text' value='' class='large' maxlength='200'     aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_9_21' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_9_21' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_9_10' class='gform_page' data-js='page-field-id-21' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_9_10' class='gform_fields top_label form_sublabel_below description_above validation_below'><fieldset id=\"field_9_22\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_9_22'>\n                            \n                            <span id='input_9_22_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_9_22_3' class='gform-field-label gform-field-label--type-sub '>Name<\/label>\n                                                    <input type='text' name='input_22.3' id='input_9_22_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_9_22_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_9_22_6' class='gform-field-label gform-field-label--type-sub '>Family name<\/label>\n                                                            <input type='text' name='input_22.6' id='input_9_22_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_9_56\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_9_56' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_9_56_1_container' >\n                                        <input type='text' name='input_56.1' id='input_9_56_1' value=''    aria-required='true'    \/>\n                                        <label for='input_9_56_1' id='input_9_56_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_9_56_3_container' >\n                                    <input type='text' name='input_56.3' id='input_9_56_3' value=''    aria-required='true'    \/>\n                                    <label for='input_9_56_3' id='input_9_56_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_9_56_4_container' >\n                                        <input type='text' name='input_56.4' id='input_9_56_4' value=''      aria-required='true'    \/>\n                                        <label for='input_9_56_4' id='input_9_56_4_label' class='gform-field-label gform-field-label--type-sub '>County \/ State \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_9_56_5_container' >\n                                    <input type='text' name='input_56.5' id='input_9_56_5' value=''    aria-required='true'    \/>\n                                    <label for='input_9_56_5' id='input_9_56_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_9_56_6_container' >\n                                        <select name='input_56.6' id='input_9_56_6'   aria-required='true'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_9_56_6' id='input_9_56_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_9_23\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_23'>E-mail address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_9_23'>Please leave your name and e-mail so we can send you the test result<\/div><div class='ginput_container ginput_container_email'>\n                            <input name='input_23' id='input_9_23' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_9_23\" \/>\n                        <\/div><\/div><div id=\"field_9_31\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_31'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_31' id='input_9_31' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_37\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_37'>How did you find us?<\/label><div class='ginput_container ginput_container_select'><select name='input_37' id='input_9_37' class='large gfield_select'     aria-invalid=\"false\" ><option value='Google search' >Google search<\/option><option value='Physiotherapist' >Physiotherapist<\/option><option value='ENT doctor \/ Neurologist' >ENT doctor \/ Neurologist<\/option><option value='Clinic' >Clinic<\/option><option value='Patient association (ie. VeDA)' >Patient association (ie. VeDA)<\/option><option value='Social Media' >Social Media<\/option><option value='Publication' >Publication<\/option><option value='Recommendation by relative \/ friend' >Recommendation by relative \/ friend<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_9_55\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_9_55'>If you have been referred to a specialist, please provide the name of the specialist.<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_9_55' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_9' class='gform_previous_button 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