{"id":1454,"date":"2016-12-29T19:54:56","date_gmt":"2016-12-29T19:54:56","guid":{"rendered":"http:\/\/www.inspa-retreats.com\/?page_id=1454"},"modified":"2017-03-14T16:54:58","modified_gmt":"2017-03-14T16:54:58","slug":"health-and-fitness-profile","status":"publish","type":"page","link":"https:\/\/inspa-retreats.com\/health-and-fitness-profile\/","title":{"rendered":"Health and fitness profile"},"content":{"rendered":"\n                <div class='gf_browser_safari gform_wrapper' id='gform_wrapper_10' style='display:none'><div id='gf_10' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_10' id='gform_10'  action='\/wp-json\/wp\/v2\/pages\/1454#gf_10'>\n                        <div class='gform_heading'>\n                            <h3 class='gform_title'>Health and fitness profile<\/h3>\n                            <span class='gform_description'>Please fill in the form below with as much information as possible. All fields marked with * are mandatory.<\/span>\n                        <\/div>\n                        <div class='gform_body'><ul id='gform_fields_10' class='gform_fields top_label form_sublabel_below description_below'><li id='field_10_11'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>1. Personal Details<\/h2><\/li><li id='field_10_1'  class='gfield gfield_contains_required field_sublabel_hidden_label field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Name<span class='gfield_required'>*<\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_10_1'>\n                            \n                            <span id='input_10_1_3_container' class='name_first' >\n                                                    <input type='text' name='input_1.3' id='input_10_1_3' value='' aria-label='First name'   aria-required=\"true\" aria-invalid=\"false\" placeholder='First Name*'\/>\n                                                    <label for='input_10_1_3' class='hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_10_1_6_container' class='name_last' >\n                                                    <input type='text' name='input_1.6' id='input_10_1_6' value='' aria-label='Last name'   aria-required=\"true\" aria-invalid=\"false\" placeholder='Surname*'\/>\n                                                    <label for='input_10_1_6' class='hidden_sub_label screen-reader-text'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id='field_10_2'  class='gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_2' >Date of Birth<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_2' id='input_10_2' type='text' value='' class='datepicker medium dmy datepicker_with_icon'   placeholder='Date of Birth*' aria-describedby='input_10_2_date_format' \/>\n                            <span id='input_10_2_date_format' class='screen-reader-text'>Date Format: DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_2' class='gform_hidden' value='https:\/\/inspa-retreats.com\/wp-content\/plugins\/gravityforms\/images\/calendar.png'\/><\/li><li id='field_10_3'  class='gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_3' >Email<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_10_3' type='text' value='' class='medium'   placeholder='Email Address*' aria-required=\"true\" aria-invalid=\"false\" \/>\n                        <\/div><\/li><li id='field_10_84'  class='gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  ><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_10_84' >\n                         <span class='ginput_full address_line_1' id='input_10_84_1_container' >\n                                        <input type='text' name='input_84.1' id='input_10_84_1' value=''   placeholder='Address Line 1' \/>\n                                        <label for='input_10_84_1' id='input_10_84_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2' id='input_10_84_2_container' >\n                                        <input type='text' name='input_84.2' id='input_10_84_2' value=''   placeholder='Address Line 1'\/>\n                                        <label for='input_10_84_2' id='input_10_84_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city' id='input_10_84_3_container' >\n                                    <input type='text' name='input_84.3' id='input_10_84_3' value=''   placeholder='City' \/>\n                                    <label for='input_10_84_3' id='input_10_84_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state' id='input_10_84_4_container' >\n                                        <input type='text' name='input_84.4' id='input_10_84_4' value=''     placeholder='State \/ Province \/ Region' \/>\n                                        <label for='input_10_84_4' id='input_10_84_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip' id='input_10_84_5_container' >\n                                    <input type='text' name='input_84.5' id='input_10_84_5' value=''   placeholder='Post Code' \/>\n                                    <label for='input_10_84_5' id='input_10_84_5_label' >Post Code<\/label>\n                                <\/span><span class='ginput_right address_country' id='input_10_84_6_container' >\n                                        <select name='input_84.6' id='input_10_84_6'   ><option value='' selected='selected'>Country<\/option><option value='Afghanistan' >Afghanistan<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/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, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/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='Czech Republic' >Czech Republic<\/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 (Swaziland)' >Eswatini (Swaziland)<\/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 and McDonald Islands' >Heard 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='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='Macau' >Macau<\/option><option value='Macedonia' >Macedonia<\/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 Korea' >North Korea<\/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='R\u00e9union' >R\u00e9union<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena' >Saint Helena<\/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' >South Georgia<\/option><option value='South Korea' >South Korea<\/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 Islands' >Svalbard and Jan Mayen Islands<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/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='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/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='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/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><\/select>\n                                        <label for='input_10_84_6' id='input_10_84_6_label' >Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id='field_10_4'  class='gfield field_sublabel_below field_description_below hidden_label gfield_visibility_hidden' ><label class='gfield_label' for='input_10_4' >Home Address<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_4' id='input_10_4' class='textarea medium'    placeholder='Home Address*'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_10_6'  class='gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_6' >Mobile telephone number<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_10_6' type='text' value='' class='medium'    placeholder='Mobile telephone number*' aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_80'  class='gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_80' >Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_80' id='input_10_80' type='text' value='' class='medium'    placeholder='Occupation'  aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_7'  class='gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_7' >Height<\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_10_7' type='text' value='' class='medium'    placeholder='Height'  aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_8'  class='gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_8' >Weight<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_10_8' type='text' value='' class='medium'    placeholder='Weight'  aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_9'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Sex<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_9'><li class='gchoice_10_9_0'><input name='input_9' type='radio' value='Male'  id='choice_10_9_0'    \/><label for='choice_10_9_0' id='label_10_9_0'>Male<\/label><\/li><li class='gchoice_10_9_1'><input name='input_9' type='radio' value='Female'  id='choice_10_9_1'    \/><label for='choice_10_9_1' id='label_10_9_1'>Female<\/label><\/li><\/ul><\/div><\/li><li id='field_10_10'  class='gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_10' >Date of Travel<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_10' id='input_10_10' type='text' value='' class='datepicker medium dmy datepicker_with_icon'   placeholder='Date of Travel' aria-describedby='input_10_10_date_format' \/>\n                            <span id='input_10_10_date_format' class='screen-reader-text'>Date Format: DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_10' class='gform_hidden' value='https:\/\/inspa-retreats.com\/wp-content\/plugins\/gravityforms\/images\/calendar.png'\/><\/li><li id='field_10_12'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><strong>Person to contact in case of emergency<\/strong><\/li><li id='field_10_13'  class='gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_13' >Name<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_10_13' type='text' value='' class='medium'    placeholder='Name'  aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_14'  class='gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_14' >Telephone<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_10_14' type='text' value='' class='medium'    placeholder='Telephone'  aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_15'  class='gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_15' >Mobile<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_10_15' type='text' value='' class='medium'    placeholder='Mobile'  aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_16'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>2. Travel Details<\/h2><\/li><li id='field_10_17'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Are you travelling on our recommended flights?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_17'><li class='gchoice_10_17_0'><input name='input_17' type='radio' value='Yes'  id='choice_10_17_0'    \/><label for='choice_10_17_0' id='label_10_17_0'>Yes<\/label><\/li><li class='gchoice_10_17_1'><input name='input_17' type='radio' value='No'  id='choice_10_17_1'    \/><label for='choice_10_17_1' id='label_10_17_1'>No<\/label><\/li><li class='gchoice_10_17_2'><input name='input_17' type='radio' value='Not yet decided'  id='choice_10_17_2'    \/><label for='choice_10_17_2' id='label_10_17_2'>Not yet decided<\/label><\/li><\/ul><\/div><\/li><li id='field_10_66'  class='gfield gsection split-start exclude field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Col Start<\/h2><\/li><li id='field_10_68'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><strong>Please provide details of your departure flights.<\/strong><\/li><li id='field_10_69'  class='gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_69' >Departure Flight Number<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_10_69' type='text' value='' class='medium'    placeholder='Departure Flight Number*' aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_70'  class='gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_70' >Date<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_70' id='input_10_70' type='text' value='' class='datepicker medium dmy datepicker_with_icon'   placeholder='Date*' aria-describedby='input_10_70_date_format' \/>\n                            <span id='input_10_70_date_format' class='screen-reader-text'>Date Format: DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_70' class='gform_hidden' value='https:\/\/inspa-retreats.com\/wp-content\/plugins\/gravityforms\/images\/calendar.png'\/><\/li><li id='field_10_71'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Departure Time<span class='gfield_required'>*<\/span><\/label><div class='clear-multi'>\n                        <div class='gfield_time_hour ginput_container ginput_container_time' id='input_10_71'>\n                            <input type='text' maxlength='2' name='input_71[]' id='input_10_71_1' value=''    \/> <i>:<\/i>\n                            <label for='input_10_71_1' >HH<\/label>\n                        <\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time'>\n                            <input type='text' maxlength='2' name='input_71[]' id='input_10_71_2' value=''    \/>\n                            <label for='input_10_71_2' >MM<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time' >\n                                \n                                <select name='input_71[]' id='input_10_71_3'   aria-label='AM\/PM'>\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select>\n                           <\/div>\n                    <\/div><\/li><li id='field_10_72'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Arrival Time<span class='gfield_required'>*<\/span><\/label><div class='clear-multi'>\n                        <div class='gfield_time_hour ginput_container ginput_container_time' id='input_10_72'>\n                            <input type='text' maxlength='2' name='input_72[]' id='input_10_72_1' value=''    \/> <i>:<\/i>\n                            <label for='input_10_72_1' >HH<\/label>\n                        <\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time'>\n                            <input type='text' maxlength='2' name='input_72[]' id='input_10_72_2' value=''    \/>\n                            <label for='input_10_72_2' >MM<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time' >\n                                \n                                <select name='input_72[]' id='input_10_72_3'   aria-label='AM\/PM'>\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select>\n                           <\/div>\n                    <\/div><\/li><li id='field_10_67'  class='gfield gsection split-end exclude field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Col End<\/h2><\/li><li id='field_10_73'  class='gfield gsection split-start exclude field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Col Start<\/h2><\/li><li id='field_10_79'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><strong>Please provide details of your return flights.<\/strong><\/li><li id='field_10_74'  class='gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_74' >Return Flight Number<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_10_74' type='text' value='' class='medium'    placeholder='Return Flight Number*' aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_77'  class='gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_77' >Date<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_77' id='input_10_77' type='text' value='' class='datepicker medium dmy datepicker_with_icon'   placeholder='Date*' aria-describedby='input_10_77_date_format' \/>\n                            <span id='input_10_77_date_format' class='screen-reader-text'>Date Format: DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_77' class='gform_hidden' value='https:\/\/inspa-retreats.com\/wp-content\/plugins\/gravityforms\/images\/calendar.png'\/><\/li><li id='field_10_76'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Departure Time<span class='gfield_required'>*<\/span><\/label><div class='clear-multi'>\n                        <div class='gfield_time_hour ginput_container ginput_container_time' id='input_10_76'>\n                            <input type='text' maxlength='2' name='input_76[]' id='input_10_76_1' value=''    \/> <i>:<\/i>\n                            <label for='input_10_76_1' >HH<\/label>\n                        <\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time'>\n                            <input type='text' maxlength='2' name='input_76[]' id='input_10_76_2' value=''    \/>\n                            <label for='input_10_76_2' >MM<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time' >\n                                \n                                <select name='input_76[]' id='input_10_76_3'   aria-label='AM\/PM'>\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select>\n                           <\/div>\n                    <\/div><\/li><li id='field_10_75'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Arrival Time<span class='gfield_required'>*<\/span><\/label><div class='clear-multi'>\n                        <div class='gfield_time_hour ginput_container ginput_container_time' id='input_10_75'>\n                            <input type='text' maxlength='2' name='input_75[]' id='input_10_75_1' value=''    \/> <i>:<\/i>\n                            <label for='input_10_75_1' >HH<\/label>\n                        <\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time'>\n                            <input type='text' maxlength='2' name='input_75[]' id='input_10_75_2' value=''    \/>\n                            <label for='input_10_75_2' >MM<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time' >\n                                \n                                <select name='input_75[]' id='input_10_75_3'   aria-label='AM\/PM'>\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select>\n                           <\/div>\n                    <\/div><\/li><li id='field_10_78'  class='gfield gsection split-end exclude field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Col End<\/h2><\/li><li id='field_10_21'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><strong>We strongly recommend that you have comprehensive travel insurance.<\/strong><\/li><li id='field_10_22'  class='gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_22' >Insurance company name<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_10_22' type='text' value='' class='medium'    placeholder='Insurance company name'  aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_23'  class='gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_23' >Insurance policy number<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_10_23' type='text' value='' class='medium'    placeholder='Insurance policy number'  aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_24'  class='gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_24' >Insurance company emergency telephone number<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_10_24' type='text' value='' class='medium'    placeholder='Insurance company emergency telephone number'  aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_25'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>4. Medical details and physical activities readiness<\/h2><\/li><li id='field_10_26'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><strong>This section of the form has been designed to identify anyone for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them.<\/strong><\/li><li id='field_10_27'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Has your doctor ever said you have heart trouble?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_27'><li class='gchoice_10_27_0'><input name='input_27' type='radio' value='Yes'  id='choice_10_27_0'    \/><label for='choice_10_27_0' id='label_10_27_0'>Yes<\/label><\/li><li class='gchoice_10_27_1'><input name='input_27' type='radio' value='No'  id='choice_10_27_1'    \/><label for='choice_10_27_1' id='label_10_27_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_10_28'  class='gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_28' >Heart Condition Details<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_10_28' type='text' value='' class='medium'    placeholder='Please specify'  aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_29'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you ever have pains in your heart and chest?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_29'><li class='gchoice_10_29_0'><input name='input_29' type='radio' value='Yes'  id='choice_10_29_0'    \/><label for='choice_10_29_0' id='label_10_29_0'>Yes<\/label><\/li><li class='gchoice_10_29_1'><input name='input_29' type='radio' value='No'  id='choice_10_29_1'    \/><label for='choice_10_29_1' id='label_10_29_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_10_30'  class='gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_30' >Pains in heart\/chest details<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_10_30' type='text' value='' class='medium'    placeholder='Please specify*' aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_31'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you ever feel faint or have spells of dizziness?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_31'><li class='gchoice_10_31_0'><input name='input_31' type='radio' value='Yes'  id='choice_10_31_0'    \/><label for='choice_10_31_0' id='label_10_31_0'>Yes<\/label><\/li><li class='gchoice_10_31_1'><input name='input_31' type='radio' value='No'  id='choice_10_31_1'    \/><label for='choice_10_31_1' id='label_10_31_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_10_32'  class='gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_32' >Dizzyness Spell Details<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_10_32' type='text' value='' class='medium'    placeholder='Please specify*' aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_33'  class='gfield field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label'  >Has your doctor ever told you that you have a bone or joint problem?<\/label><div class='gfield_description' id='gfield_description_10_33'>Such as arthritis that has been aggravated by exercise, or might be made worse with exercise? <\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_33'><li class='gchoice_10_33_0'><input name='input_33' type='radio' value='Yes'  id='choice_10_33_0'    \/><label for='choice_10_33_0' id='label_10_33_0'>Yes<\/label><\/li><li class='gchoice_10_33_1'><input name='input_33' type='radio' value='No'  id='choice_10_33_1'    \/><label for='choice_10_33_1' id='label_10_33_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_10_34'  class='gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_34' >Joint\/Bone Problem Details<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_10_34' type='text' value='' class='medium'    placeholder='Please specify*' aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_35'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you suffer from any problems of the lower back?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_35'><li class='gchoice_10_35_0'><input name='input_35' type='radio' value='Yes'  id='choice_10_35_0'    \/><label for='choice_10_35_0' id='label_10_35_0'>Yes<\/label><\/li><li class='gchoice_10_35_1'><input name='input_35' type='radio' value='No'  id='choice_10_35_1'    \/><label for='choice_10_35_1' id='label_10_35_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_10_36'  class='gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_36' >Lower Back Problem Details<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_10_36' type='text' value='' class='medium'    placeholder='Please specify*' aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_37'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Are you currently taking any medications?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_37'><li class='gchoice_10_37_0'><input name='input_37' type='radio' value='Yes'  id='choice_10_37_0'    \/><label for='choice_10_37_0' id='label_10_37_0'>Yes<\/label><\/li><li class='gchoice_10_37_1'><input name='input_37' type='radio' value='No'  id='choice_10_37_1'    \/><label for='choice_10_37_1' id='label_10_37_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_10_38'  class='gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_38' >Medication Details<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_10_38' type='text' value='' class='medium'    placeholder='Please specify*' aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_39'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you currently have a disability or a communicable disease?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_39'><li class='gchoice_10_39_0'><input name='input_39' type='radio' value='Yes'  id='choice_10_39_0'    \/><label for='choice_10_39_0' id='label_10_39_0'>Yes<\/label><\/li><li class='gchoice_10_39_1'><input name='input_39' type='radio' value='No'  id='choice_10_39_1'    \/><label for='choice_10_39_1' id='label_10_39_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_10_40'  class='gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_40' >Disability\/Communicable Disease Details<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_10_40' type='text' value='' class='medium'    placeholder='Please specify*' aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_41'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you have any other medical issues, allergies or injuries that you should inform us about?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_41'><li class='gchoice_10_41_0'><input name='input_41' type='radio' value='Yes'  id='choice_10_41_0'    \/><label for='choice_10_41_0' id='label_10_41_0'>Yes<\/label><\/li><li class='gchoice_10_41_1'><input name='input_41' type='radio' value='No'  id='choice_10_41_1'    \/><label for='choice_10_41_1' id='label_10_41_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_10_42'  class='gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_42' >Other Medical Issues\/Injuries\/Allergies Details<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_10_42' type='text' value='' class='medium'    placeholder='Please specify*' aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_43'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Is there a good physical reason, not mentioned here, why you should not follow an activity programme even if you wanted to?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_43'><li class='gchoice_10_43_0'><input name='input_43' type='radio' value='Yes'  id='choice_10_43_0'    \/><label for='choice_10_43_0' id='label_10_43_0'>Yes<\/label><\/li><li class='gchoice_10_43_1'><input name='input_43' type='radio' value='No'  id='choice_10_43_1'    \/><label for='choice_10_43_1' id='label_10_43_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_10_44'  class='gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_44' >Other reason to not follow programme Details<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_10_44' type='text' value='' class='medium'    placeholder='Please specify*' aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_45'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>5. Your current activity programme<\/h2><\/li><li id='field_10_46'  class='gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_46' >Describe your fitness level and any current form of exercise.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_46' id='input_10_46' class='textarea medium'    placeholder='Describe your fitness level and any current form of exercise.'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_10_47'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Have you practised yoga?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_47'><li class='gchoice_10_47_0'><input name='input_47' type='radio' value='Yes'  id='choice_10_47_0'    \/><label for='choice_10_47_0' id='label_10_47_0'>Yes<\/label><\/li><li class='gchoice_10_47_1'><input name='input_47' type='radio' value='No'  id='choice_10_47_1'    \/><label for='choice_10_47_1' id='label_10_47_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_10_48'  class='gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_48' >What level would you consider yourself to be?<\/label><div class='ginput_container ginput_container_select'><select name='input_48' id='input_10_48' class='medium gfield_select'    aria-invalid=\"false\"><option value='' selected='selected' class='gf_placeholder'>What level would you consider yourself to be?<\/option><option value='Beginner' >Beginner<\/option><option value='Intermediate' >Intermediate<\/option><option value='Advanced' >Advanced<\/option><\/select><\/div><\/li><li id='field_10_49'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>6. Diet<\/h2><\/li><li id='field_10_50'  class='gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_50' >Weight Aims<\/label><div class='ginput_container ginput_container_select'><select name='input_50' id='input_10_50' class='medium gfield_select'    aria-invalid=\"false\"><option value='' selected='selected' class='gf_placeholder'>Please tell us your objective regarding your weight.<\/option><option value='Lose weight' >Lose weight<\/option><option value='Gain weight' >Gain weight<\/option><option value='Stay the same' >Stay the same<\/option><\/select><\/div><\/li><li id='field_10_51'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you eat fish or seafood?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_51'><li class='gchoice_10_51_0'><input name='input_51' type='radio' value='Yes'  id='choice_10_51_0'    \/><label for='choice_10_51_0' id='label_10_51_0'>Yes<\/label><\/li><li class='gchoice_10_51_1'><input name='input_51' type='radio' value='No'  id='choice_10_51_1'    \/><label for='choice_10_51_1' id='label_10_51_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_10_52'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you eat Poultry?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_52'><li class='gchoice_10_52_0'><input name='input_52' type='radio' value='Yes'  id='choice_10_52_0'    \/><label for='choice_10_52_0' id='label_10_52_0'>Yes<\/label><\/li><li class='gchoice_10_52_1'><input name='input_52' type='radio' value='No'  id='choice_10_52_1'    \/><label for='choice_10_52_1' id='label_10_52_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_10_53'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you have any allergies?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_53'><li class='gchoice_10_53_0'><input name='input_53' type='radio' value='Yes'  id='choice_10_53_0'    \/><label for='choice_10_53_0' id='label_10_53_0'>Yes<\/label><\/li><li class='gchoice_10_53_1'><input name='input_53' type='radio' value='No'  id='choice_10_53_1'    \/><label for='choice_10_53_1' id='label_10_53_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_10_54'  class='gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_54' >My Allergies<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_54' id='input_10_54' class='textarea medium'    placeholder='If Yes, please state what you are allergic to.'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_10_55'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you have any other special dietary requirements?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_55'><li class='gchoice_10_55_0'><input name='input_55' type='radio' value='Yes'  id='choice_10_55_0'    \/><label for='choice_10_55_0' id='label_10_55_0'>Yes<\/label><\/li><li class='gchoice_10_55_1'><input name='input_55' type='radio' value='No'  id='choice_10_55_1'    \/><label for='choice_10_55_1' id='label_10_55_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_10_56'  class='gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_56' >Other Dietry Requirements<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_56' id='input_10_56' class='textarea medium'    placeholder='Please specify'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_10_57'  class='gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_57' >How many coffees\/teas do you drink per day?<\/label><div class='ginput_container ginput_container_number'><input name='input_57' id='input_10_57' type='text'    value='' class='medium'    placeholder='How many coffees\/teas do you drink per day (enter a number)?'  aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_58'  class='gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_58' >How many units of alcohol do you consumer per week?<\/label><div class='ginput_container ginput_container_number'><input name='input_58' id='input_10_58' type='text'    value='' class='medium'    placeholder='How many units of alcohol do you consumer per week (enter a number)?'  aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_59'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you smoke?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_59'><li class='gchoice_10_59_0'><input name='input_59' type='radio' value='Yes'  id='choice_10_59_0'    \/><label for='choice_10_59_0' id='label_10_59_0'>Yes<\/label><\/li><li class='gchoice_10_59_1'><input name='input_59' type='radio' value='No'  id='choice_10_59_1'    \/><label for='choice_10_59_1' id='label_10_59_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_10_60'  class='gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible' ><label class='gfield_label' for='input_10_60' >Number of cigarettes per day<\/label><div class='ginput_container ginput_container_number'><input name='input_60' id='input_10_60' type='text'    value='' class='medium'    placeholder='If so, how many 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