{"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\/nl\/do-the-test\/","title":{"rendered":"Doe de test"},"content":{"rendered":"<div id=\"fws_6a73597ad1e4f\"  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='\/nl\/wp-json\/wp\/v2\/pages\/12290#gf_9' data-formid='9' novalidate data-trp-original-action=\"\/nl\/wp-json\/wp\/v2\/pages\/12290#gf_9\"><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>Doe de test om te zien of de BalanceBelt je kan helpen je balans terug te vinden.<\/h2>\n<p>\n\n<br>\nDeze korte test helpt ons uit te vinden of de BalanceBelt uw balans en mobiliteit kan verbeteren. Als uit de test blijkt dat het zou kunnen helpen, brengen wij u in contact met een specialist voor verdere ondersteuning. Het duurt ongeveer 5 minuten om de test te voltooien.\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' >Vraag 1<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_9_47'>Geef op de eerste vraag een score voor je saldo op een schaal van 1 - 10, waarbij 10 staat voor het beste saldo dat je in je leven hebt gehad en 0 staat voor helemaal geen saldo.\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'>Als ik mijn balans een cijfer zou geven, zou het een 5 of lager zijn.<\/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'>Ik ben gediagnosticeerd met BVL, UVL of 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'>Ik heb GEEN neurologische aandoening zoals Parkinsons, Multiple Sclerose, enz.<\/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'>Ik heb GEEN beroerte gehad.<\/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'>Geen van bovenstaande.<\/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='Volgende'  \/> \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\"  >Bedankt voor uw interesse in de BalanceBelt!\n<br><br>\nUit de door u verstrekte informatie blijkt dat niet aan alle vier de voorwaarden voor optimaal gebruik van de BalanceBelt is voldaan. De vier criteria die belangrijk zijn voor een effectief gebruik van de BalanceBelt zijn:\nEen balansscore van 5 of lager op een schaal van 1 tot 10.\nGediagnosticeerd met BVL, UVL, of PPPD.\nGeen neurologische aandoeningen zoals Parkinson, Multiple Sclerose, etc.\nGeen eerdere beroerte.\n<br><br>\nAls u nog geen diagnostische test heeft gehad voor uw duizeligheid, evenwichtsverlies of slechte mobiliteit, raden wij u aan contact op te nemen met uw huisarts voor een verwijzing naar een Vestibulair Specialist die de oorzaak van uw klachten kan beoordelen. Na een diagnostische beoordeling, kunt u binnen de groep vallen voor wie de BalanceBelt hulp kan bieden.\n<br><br>\nDe BalanceBelt is speciaal ontworpen om te helpen met evenwichtsproblemen als gevolg van aandoeningen zoals unilaterale vestibulaire laesie (UVL), bilaterale vestibulaire laesie (BVL), en aanhoudende posturale-perceptuele duizeligheid (PPPD). Deze aandoeningen be\u00efnvloeden het vestibulaire systeem en veroorzaken verstoringen in hoe de hersenen balans en ruimtelijke ori\u00ebntatie waarnemen. De BalanceBelt werkt door het stimuleren van proprioceptie (het gevoel van lichaamspositie) en het herstellen van evenwicht door middel van gerichte feedback via trillingen, die bijzonder effectief is voor mensen met vestibulaire aandoeningen zoals UVL, BVL, en PPPD.\n<br><br>\nOm de effecten van de BalanceBelt te ervaren moet je evenwicht voldoende verstoord zijn (een score van 5 of minder op een schaal van 1 tot 10). Alleen dan kan de BalanceBelt de nodige prikkels geven aan de hersenen om het evenwicht te verbeteren.\n<br><br>\nIn het geval van neurologische aandoeningen zoals Parkinson of Multiple Sclerose, of na een beroerte, kunnen de oorzaken van evenwichtsproblemen complexer zijn en zijn vaak gerelateerd aan motorische stoornissen, spierzwakte, of co\u00f6rdinatieproblemen. De BalanceBelt is niet altijd effectief gebleken bij aandoeningen waarbij het evenwicht wordt be\u00efnvloed door andere factoren dan alleen het vestibulaire systeem (bijvoorbeeld door het zenuwstelsel of de hersenen). Daarom richt BalanceBelt zich voornamelijk op vestibulaire aandoeningen. \n<br><br>\nAls u niet tot de groep behoort voor wie de BalanceBelt substanti\u00eble hulp kan bieden, zijn er nog verschillende andere opties om uw balans te verbeteren. We verwijzen u graag naar de veelgestelde vragen op onze website, waar we meer informatie geven over alternatieve behandelingen.\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='vorige'  \/> <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='Volgende'  \/> \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. Gebruikt u loophulpmiddelen?<\/legend><div class='gfield_description' id='gfield_description_9_25'>(meerdere antwoorden mogelijk)<\/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'>Krukken<\/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'>Wandelstok<\/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'>Looprek<\/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'>Rolstoel<\/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'>Ik gebruik geen hulpmiddelen<\/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='vorige'  \/> <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='Volgende'  \/> \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. Hoe vaak bent u gevallen in de afgelopen 6 maanden?<\/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'>Ik ben niet gevallen<\/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'>Ik ben 1 - 2 keer gevallen<\/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'>Ik ben 3 keer of vaker gevallen<\/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='Vorige'  \/> <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='Volgende'  \/> \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. Kunt u staan en\/of lopen wanneer iemand uw hand vasthoudt?<\/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'>Nee.<\/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'>Ik kan staan.<\/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'>Ik kan staan en lopen.<\/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='Vorige'  \/> <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='Volgende'  \/> \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. Hoe zou u uw evenwicht en mobiliteit beoordelen (1 - 10)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_9_27'><br>1 = <b>zeer slecht<\/b>: Ik kan niet staan\/lopen zonder hulpmiddelen. <br>\n\n10 = <b>zeer goed<\/b>:  Zoals toen u jong was.<\/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' >Kies een nummer<\/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='Vorige'  \/> <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='Volgende'  \/> \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. Hoe is uw zicht?<\/legend><div class='gfield_description' id='gfield_description_9_16'>(meerdere antwoorden mogelijk)<\/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'>Ik zie wazig tijdens het lopen.<\/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'>Ik heb wazig zicht tijdens het reizen (trein, auto, enz.).<\/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'>Bij het lopen moet ik stilstaan om gezichten te herkennen of om borden te lezen.<\/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'>Ik zie wazig tijdens het kauwen van voedsel.<\/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'>Ik zie wazig wanneer ik snel mijn hoofd draai.<\/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'>Geen van bovenstaande.<\/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='Vorige'  \/> <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='Volgende'  \/> \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. Hoe is uw balans?<\/legend><div class='gfield_description' id='gfield_description_9_18'>Heeft u last van evenwichtsproblemen ...<\/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'>... wanneer u uw hoofd naar rechts of links draait bij het oversteken van de straat.<\/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'>... als u op oneffen oppervlakken loopt (zoals in het bos, op het strand, enz.).<\/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'>... tijdens dagelijkse activiteiten.<\/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'>... als u bij weinig licht loopt.<\/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'>... tijdens het lopen, omdat u op de grond moet letten om niet te vallen.<\/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'>Geen van bovenstaande.<\/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='Vorige'  \/> <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='Volgende'  \/> \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. Welke gediagnosticeerde aandoening heeft u?<\/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'>Bilaterale Vestibulaire Hypofunctie of Verlies (BVH of 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'>Unilaterale vestibulaire hypofunctie of verlies (UVH of 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'>Persisterende Positionele Perceptie Duizeligheid (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'>Andere aandoening<\/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'>Welke andere aandoening heeft u?<\/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='Vorige'  \/> <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='Volgende'  \/> \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' >Naam<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/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'>Naam<\/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'>Achternaam<\/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' >Adres<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/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'>Straat + huisnummer<\/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'>Plaats<\/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'>Staat \/ provincie \/ regio<\/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'>Postcode<\/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='Aland-eilanden' >Aland-eilanden<\/option><option value='Albani\u00eb' >Albani\u00eb<\/option><option value='Algerije' >Algerije<\/option><option value='Amerikaans Samoa' >Amerikaans Samoa<\/option><option value='Amerikaanse Maagdeneilanden' >Amerikaanse Maagdeneilanden<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua en Barbuda' >Antigua en Barbuda<\/option><option value='Arabische Republiek Syri\u00eb' >Arabische Republiek Syri\u00eb<\/option><option value='Argentini\u00eb' >Argentini\u00eb<\/option><option value='Armeni\u00eb' >Armeni\u00eb<\/option><option value='Aruba' >Aruba<\/option><option value='Australi\u00eb' >Australi\u00eb<\/option><option value='Azerbeidzjan' >Azerbeidzjan<\/option><option value='Bahama&#039;s' >Bahama&#039;s<\/option><option value='Bahrein' >Bahrein<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belgi\u00eb' >Belgi\u00eb<\/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 en Saba' >Bonaire, Sint Eustatius en Saba<\/option><option value='Bosni\u00eb en Herzegovina' >Bosni\u00eb en Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet eiland' >Bouvet eiland<\/option><option value='Brazili\u00eb' >Brazili\u00eb<\/option><option value='Brits-Indisch oceaan gebied' >Brits-Indisch oceaangebied<\/option><option value='Britse Maagdeneilanden' >Britse Maagdeneilanden<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgarije' >Bulgarije<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodja' >Cambodja<\/option><option value='Canada' >Canada<\/option><option value='Centraal-Afrikaanse Republiek' >Centraal-Afrikaanse Republiek<\/option><option value='Chili' >Chili<\/option><option value='China' >China<\/option><option value='Cocoseilanden' >Cocoseilanden<\/option><option value='Colombia' >Colombia<\/option><option value='Comoren' >Comoren<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratische Republiek' >Congo, Democratische Republiek<\/option><option value='Cook eilanden' >Koken eilanden<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Denemarken' >Denemarken<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominicaanse Republiek' >Dominicaanse Republiek<\/option><option value='Duitsland' >Duitsland<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypte' >Egypte<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatoriaal-Guinea' >Equatoriaal-Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estland' >Estland<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopi\u00eb' >Ethiopi\u00eb<\/option><option value='Faer\u00f6er' >Faer\u00f6er<\/option><option value='Falkland eilanden' >Falkland eilanden<\/option><option value='Fiji' >Fiji<\/option><option value='Filipijnen' >Filipijnen<\/option><option value='Finland' >Finland<\/option><option value='Frankrijk' >Frankrijk<\/option><option value='Frans Guyana' >Frans Guyana<\/option><option value='Frans-Polynesi\u00eb' >Frans-Polynesi\u00eb<\/option><option value='Franse zuidelijke gebieden' >Franse zuidelijke gebieden<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgi\u00eb' >Georgi\u00eb<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Grenada' >Grenada<\/option><option value='Griekenland' >Griekenland<\/option><option value='Groenland' >Groenland<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinee' >Guinee<\/option><option value='Guinee-Bissau' >Guinee-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Ha\u00efti' >Ha\u00efti<\/option><option value='Heard Eiland en McDonald Eilanden' >Heard Eiland en McDonald Eilanden<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hongkong<\/option><option value='Hongarije' >Hongarije<\/option><option value='IJsland' >IJsland<\/option><option value='Ierland' >Ierland<\/option><option value='India' >India<\/option><option value='Indonesi\u00eb' >Indonesi\u00eb<\/option><option value='Irak' >Irak<\/option><option value='Iran' >Iran<\/option><option value='Isra\u00ebl' >Isra\u00ebl<\/option><option value='Itali\u00eb' >Itali\u00eb<\/option><option value='Ivoorkust' >Ivoorkust<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy' >Ji\u017en\u00ed Georgie en Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='Jordani\u00eb' >Jordani\u00eb<\/option><option value='Kaaimaneilanden' >Kaaimaneilanden<\/option><option value='Kaapverdi\u00eb' >Kaapverdi\u00eb<\/option><option value='Kameroen' >Kameroen<\/option><option value='Kazachstan' >Kazachstan<\/option><option value='Kenia' >Kenia<\/option><option value='Kersteiland' >Kersteiland<\/option><option value='Kirgizi\u00eb' >Kirgizi\u00eb<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kleine eilanden van de Verenigde Staten' >Kleine eilanden van de Verenigde Staten<\/option><option value='Koeweit' >Koeweit<\/option><option value='Korea, Democratische Volksrepubliek' >Korea, Democratische Volksrepubliek<\/option><option value='Korea, Republiek van' >Korea, Republiek van<\/option><option value='Kroati\u00eb' >Kroati\u00eb<\/option><option value='Lao Democratische Volksrepubliek' >Laos Democratische Volksrepubliek<\/option><option value='Lesotho' >Lesotho<\/option><option value='Letland' >Letland<\/option><option value='Libanon' >Libanon<\/option><option value='Liberia' >Liberia<\/option><option value='Libi\u00eb' >Libi\u00eb<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Litouwen' >Litouwen<\/option><option value='Luxemburg' >Luxemburg<\/option><option value='Macau' >Macau<\/option><option value='Madagaskar' >Madagaskar<\/option><option value='Malawi' >Malawi<\/option><option value='Maldiven' >Maldiven<\/option><option value='Maleisi\u00eb' >Maleisi\u00eb<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Man' >Man<\/option><option value='Marokko' >Marokko<\/option><option value='Marshalleilanden' >Marshalleilanden<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritani\u00eb' >Mauritani\u00eb<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesi\u00eb<\/option><option value='Moldavi\u00eb' >Moldavi\u00eb<\/option><option value='Monaco' >Monaco<\/option><option value='Mongoli\u00eb' >Mongoli\u00eb<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibi\u00eb' >Namibi\u00eb<\/option><option value='Nauru' >Nauru<\/option><option value='Nederland' >Nederland<\/option><option value='Nepal' >Nepal<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Nieuw-Caledoni\u00eb' >Nieuw-Caledoni\u00eb<\/option><option value='Nieuw-Zeeland' >Nieuw-Zeeland<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Noord-Macedoni\u00eb' >Noord-Macedoni\u00eb<\/option><option value='Noordelijke Marianen' >Noordelijke Marianen<\/option><option value='Noorwegen' >Noorwegen<\/option><option value='Norfolk eiland' >Norfolk eiland<\/option><option value='Oeganda' >Oeganda<\/option><option value='Oekra\u00efne' >Oekra\u00efne<\/option><option value='Oezbekistan' >Oezbekistan<\/option><option value='Oman' >Oman<\/option><option value='Oostenrijk' >Oostenrijk<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestina, Staat' >Palestina, Staat<\/option><option value='Panama' >Panama<\/option><option value='Papoea-Nieuw-Guinea' >Papoea-Nieuw-Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Polen' >Polen<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Roemeni\u00eb' >Roemeni\u00eb<\/option><option value='Russische Federatie' >Russische Federatie<\/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 Kitts en Nevis' >Saint Kitts en Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Pierre en Miquelon' >Saint-Pierre en Miquelon<\/option><option value='Saint Vincent en de Grenadines' >Saint Vincent en de Grenadines<\/option><option value='Salomonseilanden' >Salomonseilanden<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tom\u00e9 en Principe' >Sao Tom\u00e9 en Principe<\/option><option value='Saoedi-Arabi\u00eb' >Saoedi-Arabi\u00eb<\/option><option value='Senegal' >Senegal<\/option><option value='Servi\u00eb' >Diensten<\/option><option value='Seychellen' >Seychellen<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Sint-Helena, Hemelvaart en Tristan da Cunha' >Sint-Helena, Hemelvaart en Tristan da Cunha<\/option><option value='Sloveni\u00eb' >Sloveni\u00eb<\/option><option value='Slowakije' >Slowakije<\/option><option value='Soedan' >Soedan<\/option><option value='Somali\u00eb' >Somali\u00eb<\/option><option value='Spanje' >Spanje<\/option><option value='Spitsbergen en Jan Mayen' >Spitsbergen en Jan Mayen<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Suriname' >Suriname<\/option><option value='Tadzjikistan' >Tadzjikistan<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tanzania, de Verenigde Republiek van' >Tanzania, de Verenigde Republiek van<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Oost-Timor<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad en Tobago' >Trinidad en Tobago<\/option><option value='Tsjaad' >Tsjaad<\/option><option value='Tsjechi\u00eb' >Tsjechi\u00eb<\/option><option value='Tunesi\u00eb' >Tunesi\u00eb<\/option><option value='Turkije' >Turkije<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks- en Caicoseilanden' >Turks- en Caicoseilanden<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='Uruguay' >Uruguay<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Vaticaanstad' >Vaticaanstad<\/option><option value='Venezuela' >Venezuela<\/option><option value='Verenigd Koninkrijk' >Verenigd Koninkrijk<\/option><option value='Verenigde Arabische Emiraten' >Verenigde Arabische Emiraten<\/option><option value='Verenigde Staten' >Verenigde Staten<\/option><option value='Vietnam' >Vietnam<\/option><option value='Wallis en Futuna' >Wallis en Futuna<\/option><option value='Westelijke Sahara' >Westelijke Sahara<\/option><option value='Wit-Rusland' >Wit-Rusland<\/option><option value='Yemen' >Jemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='Zuid Soedan' >Zuid Soedan<\/option><option value='Zuid-Afrika' >Zuid-Afrika<\/option><option value='Zweden' >Zweden<\/option><option value='Zwitserland' >Zwitserland<\/option><\/select>\n                                        <label for='input_9_56_6' id='input_9_56_6_label' class='gform-field-label gform-field-label--type-sub'>Land<\/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 adres<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_9_23'>Gelieve uw naam en e-mailadres achter te laten zodat we u de testresultaten kunnen sturen.<\/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'>Telefoon<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/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'>Hoe heeft u ons gevonden?<\/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' >Zoeken met Google<\/option><option value='Physiotherapist' >Fysiotherapeut<\/option><option value='ENT doctor \/ Neurologist' >KNO-arts \/ Neuroloog<\/option><option value='Clinic' >Kliniek<\/option><option value='Patient association (ie. VeDA)' >Pati\u00ebntenvereniging (bijv. denegendevan, st. 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