{"id":2342,"date":"2023-09-21T16:12:03","date_gmt":"2023-09-21T16:12:03","guid":{"rendered":"https:\/\/metamorapt.com\/?page_id=2342"},"modified":"2023-10-06T15:42:52","modified_gmt":"2023-10-06T15:42:52","slug":"dizziness-vertigo-form","status":"publish","type":"page","link":"https:\/\/metamorapt.com\/dizziness-vertigo-form\/","title":{"rendered":"Dizziness Vertigo Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"2342\" class=\"elementor elementor-2342\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-e976d99 elementor-section-stretched elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"e976d99\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;stretch_section&quot;:&quot;section-stretched&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-097ee13\" data-id=\"097ee13\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-a8e77c9 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"a8e77c9\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-bf75c63\" data-id=\"bf75c63\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-220b646 elementor-widget elementor-widget-heading\" data-id=\"220b646\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Dizziness Vertigo Form<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-2fe4ec1 elementor-section-stretched elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"2fe4ec1\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;stretch_section&quot;:&quot;section-stretched&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-41c414f\" data-id=\"41c414f\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-2ddc04f elementor-widget elementor-widget-heading\" data-id=\"2ddc04f\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Become a Patient<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-f972652 elementor-widget elementor-widget-text-editor\" data-id=\"f972652\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"wpb_text_column wpb_content_element \"><div class=\"wpb_wrapper\"><p class=\"p1\"><span class=\"s1\">Simply fill out the form online to enroll as a new patient. We&#8217;re excited for you to visit us!<\/span><\/p><\/div><\/div>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-aa30b8f elementor-widget-divider--view-line elementor-widget elementor-widget-divider\" data-id=\"aa30b8f\" data-element_type=\"widget\" data-widget_type=\"divider.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-divider\">\n\t\t\t<span class=\"elementor-divider-separator\">\n\t\t\t\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-b1e3821 elementor-widget elementor-widget-shortcode\" data-id=\"b1e3821\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-shortcode\"><noscript class=\"ninja-forms-noscript-message\">\n\tNotice: JavaScript is required for this content.<\/noscript>\n<style>\n\n        \/* FIELDS 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nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Illinois\",\"value\":\"IL\",\"calc\":\"\",\"selected\":0,\"order\":13,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Indiana\",\"value\":\"IN\",\"calc\":\"\",\"selected\":0,\"order\":14,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Iowa\",\"value\":\"IA\",\"calc\":\"\",\"selected\":0,\"order\":15,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a 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Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Maine\",\"value\":\"ME\",\"calc\":\"\",\"selected\":0,\"order\":19,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Maryland\",\"value\":\"MD\",\"calc\":\"\",\"selected\":0,\"order\":20,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Massachusetts\",\"value\":\"MA\",\"calc\":\"\",\"selected\":0,\"order\":21,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Michigan\",\"value\":\"MI\",\"calc\":\"\",\"selected\":0,\"order\":22,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Minnesota\",\"value\":\"MN\",\"calc\":\"\",\"selected\":0,\"order\":23,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" 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aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Nebraska\",\"value\":\"NE\",\"calc\":\"\",\"selected\":0,\"order\":27,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i 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Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Ohio\",\"value\":\"OH\",\"calc\":\"\",\"selected\":0,\"order\":35,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Oklahoma\",\"value\":\"OK\",\"calc\":\"\",\"selected\":0,\"order\":36,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i 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nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Pennsylvania\",\"value\":\"PA\",\"calc\":\"\",\"selected\":0,\"order\":38,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Rhode Island\",\"value\":\"RI\",\"calc\":\"\",\"selected\":0,\"order\":39,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" 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Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Texas\",\"value\":\"TX\",\"calc\":\"\",\"selected\":0,\"order\":43,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Utah\",\"value\":\"UT\",\"calc\":\"\",\"selected\":0,\"order\":44,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa 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nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Virginia\",\"value\":\"VA\",\"calc\":\"\",\"selected\":0,\"order\":46,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a 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this a worker's compensation claim?\",\"field_key\":\"is_this_a_worker_s_compensation_claim_1695863235151\",\"id\":678,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"parentType\":\"list\",\"element_templates\":[\"listcheckbox\",\"input\"],\"old_classname\":\"list-checkbox\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":37,\"idAttribute\":\"id\",\"type\":\"html\",\"label\":\"If yes, please complete the following:\",\"default\":\"If yes, please complete the following:\",\"container_class\":\"\",\"element_class\":\"\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"cellcid\":\"c4466\",\"key\":\"if_yes_please_complete_the_following_1695863293889\",\"drawerDisabled\":\"\",\"field_label\":\"If yes, please complete the following:\",\"field_key\":\"if_yes_please_complete_the_following_1695863293889\",\"id\":679,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"If yes, please complete the following:\",\"label_pos\":\"above\",\"parentType\":\"html\",\"element_templates\":[\"html\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":38,\"idAttribute\":\"id\",\"type\":\"firstname\",\"label\":\"Employer's Name\",\"key\":\"employer_s_name_1695863386865\",\"label_pos\":\"above\",\"required\":\"\",\"default\":\"\",\"placeholder\":\"\",\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"custom_name_attribute\":\"fname\",\"personally_identifiable\":1,\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"cellcid\":\"c4469\",\"value\":\"\",\"drawerDisabled\":\"\",\"field_label\":\"Employer's Name\",\"field_key\":\"employer_s_name_1695863386865\",\"id\":680,\"beforeField\":\"\",\"afterField\":\"\",\"parentType\":\"firstname\",\"element_templates\":[\"firstname\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":39,\"idAttribute\":\"id\",\"label\":\"Employer's Phone Number\",\"type\":\"phone\",\"cellcid\":\"c4471\",\"key\":\"employer_s_phone_number_1695863411695\",\"label_pos\":\"above\",\"required\":\"\",\"default\":\"\",\"placeholder\":\"\",\"container_class\":\"\",\"element_class\":\"\",\"input_limit\":\"\",\"input_limit_type\":\"characters\",\"input_limit_msg\":\"Character(s) left\",\"manual_key\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"mask\":\"\",\"custom_mask\":\"\",\"custom_name_attribute\":\"phone\",\"personally_identifiable\":1,\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"value\":\"\",\"drawerDisabled\":\"\",\"field_label\":\"Employer's Phone Number\",\"field_key\":\"employer_s_phone_number_1695863411695\",\"id\":681,\"beforeField\":\"\",\"afterField\":\"\",\"parentType\":\"textbox\",\"element_templates\":[\"tel\",\"textbox\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":40,\"idAttribute\":\"id\",\"type\":\"city\",\"label\":\"City\",\"key\":\"city_1695863442508\",\"label_pos\":\"above\",\"required\":\"\",\"default\":\"\",\"placeholder\":\"\",\"container_class\":\"\",\"element_class\":\"\",\"input_limit\":\"\",\"input_limit_type\":\"characters\",\"input_limit_msg\":\"Character(s) left\",\"manual_key\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"mask\":\"\",\"custom_mask\":\"\",\"custom_name_attribute\":\"city\",\"personally_identifiable\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_show_advanced_css\":0,\"element_styles_show_advanced_css\":0,\"cellcid\":\"c4474\",\"value\":\"\",\"field_label\":\"City\",\"field_key\":\"city_1695863442508\",\"id\":682,\"beforeField\":\"\",\"afterField\":\"\",\"parentType\":\"city\",\"element_templates\":[\"city\",\"textbox\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":41,\"idAttribute\":\"id\",\"type\":\"liststate\",\"label\":\"State\",\"key\":\"state_1695863472593\",\"label_pos\":\"above\",\"required\":\"\",\"options\":[{\"errors\":[],\"max_options\":0,\"label\":\"- Select State -\",\"value\":\"\",\"calc\":\"\",\"selected\":0,\"order\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Alabama\",\"value\":\"AL\",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Alaska\",\"value\":\"AK\",\"calc\":\"\",\"selected\":0,\"order\":2,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Arizona\",\"value\":\"AZ\",\"calc\":\"\",\"selected\":0,\"order\":3,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Arkansas\",\"value\":\"AR\",\"calc\":\"\",\"selected\":0,\"order\":4,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"California\",\"value\":\"CA\",\"calc\":\"\",\"selected\":0,\"order\":5,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Colorado\",\"value\":\"CO\",\"calc\":\"\",\"selected\":0,\"order\":6,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Connecticut\",\"value\":\"CT\",\"calc\":\"\",\"selected\":0,\"order\":7,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Delaware\",\"value\":\"DE\",\"calc\":\"\",\"selected\":0,\"order\":8,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Florida\",\"value\":\"FL\",\"calc\":\"\",\"selected\":0,\"order\":9,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Georgia\",\"value\":\"GA\",\"calc\":\"\",\"selected\":0,\"order\":10,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Hawaii\",\"value\":\"HI\",\"calc\":\"\",\"selected\":0,\"order\":11,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Idaho\",\"value\":\"ID\",\"calc\":\"\",\"selected\":0,\"order\":12,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Illinois\",\"value\":\"IL\",\"calc\":\"\",\"selected\":0,\"order\":13,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Indiana\",\"value\":\"IN\",\"calc\":\"\",\"selected\":0,\"order\":14,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Iowa\",\"value\":\"IA\",\"calc\":\"\",\"selected\":0,\"order\":15,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Kansas\",\"value\":\"KS\",\"calc\":\"\",\"selected\":0,\"order\":16,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Kentucky\",\"value\":\"KY\",\"calc\":\"\",\"selected\":0,\"order\":17,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Louisiana\",\"value\":\"LA\",\"calc\":\"\",\"selected\":0,\"order\":18,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Maine\",\"value\":\"ME\",\"calc\":\"\",\"selected\":0,\"order\":19,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons 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Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Minnesota\",\"value\":\"MN\",\"calc\":\"\",\"selected\":0,\"order\":23,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Mississippi\",\"value\":\"MS\",\"calc\":\"\",\"selected\":0,\"order\":24,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Missouri\",\"value\":\"MO\",\"calc\":\"\",\"selected\":0,\"order\":25,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Montana\",\"value\":\"MT\",\"calc\":\"\",\"selected\":0,\"order\":26,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Nebraska\",\"value\":\"NE\",\"calc\":\"\",\"selected\":0,\"order\":27,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Nevada\",\"value\":\"NV\",\"calc\":\"\",\"selected\":0,\"order\":28,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"New 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Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"North Carolina\",\"value\":\"NC\",\"calc\":\"\",\"selected\":0,\"order\":33,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"North Dakota\",\"value\":\"ND\",\"calc\":\"\",\"selected\":0,\"order\":34,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i 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nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Oklahoma\",\"value\":\"OK\",\"calc\":\"\",\"selected\":0,\"order\":36,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Oregon\",\"value\":\"OR\",\"calc\":\"\",\"selected\":0,\"order\":37,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" 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Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"South Carolina\",\"value\":\"SC\",\"calc\":\"\",\"selected\":0,\"order\":40,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"South Dakota\",\"value\":\"SD\",\"calc\":\"\",\"selected\":0,\"order\":41,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Tennessee\",\"value\":\"TN\",\"calc\":\"\",\"selected\":0,\"order\":42,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Texas\",\"value\":\"TX\",\"calc\":\"\",\"selected\":0,\"order\":43,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Utah\",\"value\":\"UT\",\"calc\":\"\",\"selected\":0,\"order\":44,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}},{\"errors\":[],\"max_options\":0,\"label\":\"Vermont\",\"value\":\"VT\",\"calc\":\"\",\"selected\":0,\"order\":45,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" 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nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":20,\"new\":false,\"options\":[],\"label\":\"Diabetes\",\"value\":\"twenty one \",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a 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\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons 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Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":23,\"new\":false,\"options\":[],\"label\":\"Ulcer or digestive disorder\",\"value\":\"twenty four \",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":24,\"new\":false,\"options\":[],\"label\":\"Respiratory disorder\",\"value\":\"twenty five \",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons 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Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":26,\"new\":false,\"options\":[],\"label\":\"Stroke\",\"value\":\"twenty seven \",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":27,\"new\":false,\"options\":[],\"label\":\"Metal implants \",\"value\":\"twenty eight \",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":28,\"new\":false,\"options\":[],\"label\":\"Seizures \",\"value\":\"twenty 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Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":31,\"new\":false,\"options\":[],\"label\":\"Urinary or bowel incontinence\",\"value\":\"thirty two \",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":32,\"new\":false,\"options\":[],\"label\":\"Fractures\",\"value\":\"thirty 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Please answer every question, based on your condition in the last week, by selecting the appropriate number.<br><br><\\\/p>\",\"container_class\":\"\",\"element_class\":\"\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"cellcid\":\"c4582\",\"key\":\"instructions_1696601357637\",\"drawerDisabled\":\"\",\"field_label\":\"INSTRUCTIONS\",\"field_key\":\"instructions_1696601357637\",\"id\":717,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"<p><b>INSTRUCTIONS:&nbsp;<\\\/b><\\\/p><p>This questionnaire asks about your symptoms as well as your ability to perform certain activities. 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Please rate your pain level with activity: NO PAIN = 0 1 2 3 4 5 6 7 8 9 10= VERY SEVERE PAIN\",\"field_key\":\"1_please_rate_your_pain_level_with_activity_no_pain_0_1_2_3_4_5_6_7_8_9_10_very_severe_pain_1696601493802\",\"id\":761,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"<p><b>SECTION II: <\\\/b><\\\/p><p>The purpose of this scale is to identify difficulties that you may be experiencing because of your dizziness or unsteadiness. Please indicate by selecting \\\"Yes\\\" or \\\"No\\\" or \\\"Sometimes\\\" for each question. Answer each question as it pertains to your dizziness or unsteadiness problem only.<\\\/p><p><br><\\\/p>\",\"label_pos\":\"above\",\"parentType\":\"html\",\"element_templates\":[\"html\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":81,\"idAttribute\":\"id\",\"type\":\"listradio\",\"label\":\"P1. 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Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"No (2) \",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":2,\"new\":false,\"options\":[],\"label\":\"Sometimes (3)\",\"value\":\"sometimes-3\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}}],\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"list_item_row_styles_border\":\"\",\"list_item_row_styles_height\":\"\",\"list_item_row_styles_width\":\"\",\"list_item_row_styles_font-size\":\"\",\"list_item_row_styles_margin\":\"\",\"list_item_row_styles_padding\":\"\",\"list_item_row_styles_float\":\"\",\"list_item_row_styles_show_advanced_css\":0,\"list_item_label_styles_border\":\"\",\"list_item_label_styles_height\":\"\",\"list_item_label_styles_width\":\"\",\"list_item_label_styles_font-size\":\"\",\"list_item_label_styles_margin\":\"\",\"list_item_label_styles_padding\":\"\",\"list_item_label_styles_float\":\"\",\"list_item_label_styles_show_advanced_css\":0,\"list_item_element_styles_border\":\"\",\"list_item_element_styles_height\":\"\",\"list_item_element_styles_width\":\"\",\"list_item_element_styles_font-size\":\"\",\"list_item_element_styles_margin\":\"\",\"list_item_element_styles_padding\":\"\",\"list_item_element_styles_float\":\"\",\"list_item_element_styles_show_advanced_css\":0,\"cellcid\":\"c4591\",\"drawerDisabled\":false,\"field_label\":\"1. Open a tight or new jar\",\"field_key\":\"1_open_a_tight_or_new_jar_1696601523145\",\"id\":718,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"parentType\":\"list\",\"element_templates\":[\"listradio\",\"input\"],\"old_classname\":\"list-radio\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":82,\"idAttribute\":\"id\",\"type\":\"listradio\",\"label\":\"E2. Because of your problem, doe you feel frustrated? \",\"key\":\"e2_because_of_your_problem_doe_you_feel_frustrated_1696605820290\",\"label_pos\":\"above\",\"required\":1,\"options\":[{\"errors\":[],\"max_options\":0,\"label\":\"Yes (1)\",\"value\":\"one \",\"calc\":\"\",\"selected\":0,\"order\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"No (2) \",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":2,\"new\":false,\"options\":[],\"label\":\"Sometimes (3)\",\"value\":\"sometimes-3\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}}],\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"list_item_row_styles_border\":\"\",\"list_item_row_styles_height\":\"\",\"list_item_row_styles_width\":\"\",\"list_item_row_styles_font-size\":\"\",\"list_item_row_styles_margin\":\"\",\"list_item_row_styles_padding\":\"\",\"list_item_row_styles_float\":\"\",\"list_item_row_styles_show_advanced_css\":0,\"list_item_label_styles_border\":\"\",\"list_item_label_styles_height\":\"\",\"list_item_label_styles_width\":\"\",\"list_item_label_styles_font-size\":\"\",\"list_item_label_styles_margin\":\"\",\"list_item_label_styles_padding\":\"\",\"list_item_label_styles_float\":\"\",\"list_item_label_styles_show_advanced_css\":0,\"list_item_element_styles_border\":\"\",\"list_item_element_styles_height\":\"\",\"list_item_element_styles_width\":\"\",\"list_item_element_styles_font-size\":\"\",\"list_item_element_styles_margin\":\"\",\"list_item_element_styles_padding\":\"\",\"list_item_element_styles_float\":\"\",\"list_item_element_styles_show_advanced_css\":0,\"cellcid\":\"c4594\",\"drawerDisabled\":false,\"field_label\":\"1. Open a tight or new jar\",\"field_key\":\"1_open_a_tight_or_new_jar_1696601523145\",\"id\":762,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"parentType\":\"list\",\"element_templates\":[\"listradio\",\"input\"],\"old_classname\":\"list-radio\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":83,\"idAttribute\":\"id\",\"type\":\"listradio\",\"label\":\"F3. Because of your problem, do you restrict your travel for business or recreation?\",\"key\":\"f3_because_of_your_problem_do_you_restrict_your_travel_for_business_or_recreation_1696605847457\",\"label_pos\":\"above\",\"required\":1,\"options\":[{\"errors\":[],\"max_options\":0,\"label\":\"Yes (1)\",\"value\":\"one \",\"calc\":\"\",\"selected\":0,\"order\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"No (2) \",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":2,\"new\":false,\"options\":[],\"label\":\"Sometimes (3)\",\"value\":\"sometimes-3\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}}],\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"list_item_row_styles_border\":\"\",\"list_item_row_styles_height\":\"\",\"list_item_row_styles_width\":\"\",\"list_item_row_styles_font-size\":\"\",\"list_item_row_styles_margin\":\"\",\"list_item_row_styles_padding\":\"\",\"list_item_row_styles_float\":\"\",\"list_item_row_styles_show_advanced_css\":0,\"list_item_label_styles_border\":\"\",\"list_item_label_styles_height\":\"\",\"list_item_label_styles_width\":\"\",\"list_item_label_styles_font-size\":\"\",\"list_item_label_styles_margin\":\"\",\"list_item_label_styles_padding\":\"\",\"list_item_label_styles_float\":\"\",\"list_item_label_styles_show_advanced_css\":0,\"list_item_element_styles_border\":\"\",\"list_item_element_styles_height\":\"\",\"list_item_element_styles_width\":\"\",\"list_item_element_styles_font-size\":\"\",\"list_item_element_styles_margin\":\"\",\"list_item_element_styles_padding\":\"\",\"list_item_element_styles_float\":\"\",\"list_item_element_styles_show_advanced_css\":0,\"cellcid\":\"c4597\",\"drawerDisabled\":false,\"field_label\":\"1. Open a tight or new jar\",\"field_key\":\"1_open_a_tight_or_new_jar_1696601523145\",\"id\":763,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"parentType\":\"list\",\"element_templates\":[\"listradio\",\"input\"],\"old_classname\":\"list-radio\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":84,\"idAttribute\":\"id\",\"type\":\"listradio\",\"label\":\"P4. Does walking down the aisle of a supermarket increase your problem?\",\"key\":\"p4_does_walking_down_the_aisle_of_a_supermarket_increase_your_problem_1696605869791\",\"label_pos\":\"above\",\"required\":1,\"options\":[{\"errors\":[],\"max_options\":0,\"label\":\"Yes (1)\",\"value\":\"one \",\"calc\":\"\",\"selected\":0,\"order\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"No (2) \",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":2,\"new\":false,\"options\":[],\"label\":\"Sometimes (3)\",\"value\":\"sometimes-3\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}}],\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"list_item_row_styles_border\":\"\",\"list_item_row_styles_height\":\"\",\"list_item_row_styles_width\":\"\",\"list_item_row_styles_font-size\":\"\",\"list_item_row_styles_margin\":\"\",\"list_item_row_styles_padding\":\"\",\"list_item_row_styles_float\":\"\",\"list_item_row_styles_show_advanced_css\":0,\"list_item_label_styles_border\":\"\",\"list_item_label_styles_height\":\"\",\"list_item_label_styles_width\":\"\",\"list_item_label_styles_font-size\":\"\",\"list_item_label_styles_margin\":\"\",\"list_item_label_styles_padding\":\"\",\"list_item_label_styles_float\":\"\",\"list_item_label_styles_show_advanced_css\":0,\"list_item_element_styles_border\":\"\",\"list_item_element_styles_height\":\"\",\"list_item_element_styles_width\":\"\",\"list_item_element_styles_font-size\":\"\",\"list_item_element_styles_margin\":\"\",\"list_item_element_styles_padding\":\"\",\"list_item_element_styles_float\":\"\",\"list_item_element_styles_show_advanced_css\":0,\"cellcid\":\"c4600\",\"drawerDisabled\":false,\"field_label\":\"1. Open a tight or new jar\",\"field_key\":\"1_open_a_tight_or_new_jar_1696601523145\",\"id\":764,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"parentType\":\"list\",\"element_templates\":[\"listradio\",\"input\"],\"old_classname\":\"list-radio\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":85,\"idAttribute\":\"id\",\"type\":\"listradio\",\"label\":\"F5. Because of your problem, do you have difficulty getting into or out of bed? \",\"key\":\"f5_because_of_your_problem_do_you_have_difficulty_getting_into_or_out_of_bed_1696605892741\",\"label_pos\":\"above\",\"required\":1,\"options\":[{\"errors\":[],\"max_options\":0,\"label\":\"Yes (1)\",\"value\":\"one \",\"calc\":\"\",\"selected\":0,\"order\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"No (2) \",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":2,\"new\":false,\"options\":[],\"label\":\"Sometimes (3)\",\"value\":\"sometimes-3\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}}],\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"list_item_row_styles_border\":\"\",\"list_item_row_styles_height\":\"\",\"list_item_row_styles_width\":\"\",\"list_item_row_styles_font-size\":\"\",\"list_item_row_styles_margin\":\"\",\"list_item_row_styles_padding\":\"\",\"list_item_row_styles_float\":\"\",\"list_item_row_styles_show_advanced_css\":0,\"list_item_label_styles_border\":\"\",\"list_item_label_styles_height\":\"\",\"list_item_label_styles_width\":\"\",\"list_item_label_styles_font-size\":\"\",\"list_item_label_styles_margin\":\"\",\"list_item_label_styles_padding\":\"\",\"list_item_label_styles_float\":\"\",\"list_item_label_styles_show_advanced_css\":0,\"list_item_element_styles_border\":\"\",\"list_item_element_styles_height\":\"\",\"list_item_element_styles_width\":\"\",\"list_item_element_styles_font-size\":\"\",\"list_item_element_styles_margin\":\"\",\"list_item_element_styles_padding\":\"\",\"list_item_element_styles_float\":\"\",\"list_item_element_styles_show_advanced_css\":0,\"cellcid\":\"c4603\",\"drawerDisabled\":false,\"field_label\":\"1. Open a tight or new jar\",\"field_key\":\"1_open_a_tight_or_new_jar_1696601523145\",\"id\":765,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"parentType\":\"list\",\"element_templates\":[\"listradio\",\"input\"],\"old_classname\":\"list-radio\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":86,\"idAttribute\":\"id\",\"type\":\"listradio\",\"label\":\"F6. Does your problem significantly restrict your participation in social activities such as going out to dinner, going to the movies, dancing, or to parties? \",\"key\":\"f6_does_your_problem_significantly_restrict_your_participation_in_social_activities_such_as_going_out_to_dinner_going_to_the_movies_dancing_or_to_parties_1696605936266\",\"label_pos\":\"above\",\"required\":1,\"options\":[{\"errors\":[],\"max_options\":0,\"label\":\"Yes (1)\",\"value\":\"one \",\"calc\":\"\",\"selected\":0,\"order\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"No (2) \",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":2,\"new\":false,\"options\":[],\"label\":\"Sometimes (3)\",\"value\":\"sometimes-3\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}}],\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"list_item_row_styles_border\":\"\",\"list_item_row_styles_height\":\"\",\"list_item_row_styles_width\":\"\",\"list_item_row_styles_font-size\":\"\",\"list_item_row_styles_margin\":\"\",\"list_item_row_styles_padding\":\"\",\"list_item_row_styles_float\":\"\",\"list_item_row_styles_show_advanced_css\":0,\"list_item_label_styles_border\":\"\",\"list_item_label_styles_height\":\"\",\"list_item_label_styles_width\":\"\",\"list_item_label_styles_font-size\":\"\",\"list_item_label_styles_margin\":\"\",\"list_item_label_styles_padding\":\"\",\"list_item_label_styles_float\":\"\",\"list_item_label_styles_show_advanced_css\":0,\"list_item_element_styles_border\":\"\",\"list_item_element_styles_height\":\"\",\"list_item_element_styles_width\":\"\",\"list_item_element_styles_font-size\":\"\",\"list_item_element_styles_margin\":\"\",\"list_item_element_styles_padding\":\"\",\"list_item_element_styles_float\":\"\",\"list_item_element_styles_show_advanced_css\":0,\"cellcid\":\"c4606\",\"drawerDisabled\":false,\"field_label\":\"1. Open a tight or new jar\",\"field_key\":\"1_open_a_tight_or_new_jar_1696601523145\",\"id\":766,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"parentType\":\"list\",\"element_templates\":[\"listradio\",\"input\"],\"old_classname\":\"list-radio\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":87,\"idAttribute\":\"id\",\"type\":\"listradio\",\"label\":\"F7. Because of your problem, do you have difficulty reading? \",\"key\":\"f7_because_of_your_problem_do_you_have_difficulty_reading_1696605956950\",\"label_pos\":\"above\",\"required\":1,\"options\":[{\"errors\":[],\"max_options\":0,\"label\":\"Yes (1)\",\"value\":\"one \",\"calc\":\"\",\"selected\":0,\"order\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"No (2) \",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":2,\"new\":false,\"options\":[],\"label\":\"Sometimes (3)\",\"value\":\"sometimes-3\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}}],\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"list_item_row_styles_border\":\"\",\"list_item_row_styles_height\":\"\",\"list_item_row_styles_width\":\"\",\"list_item_row_styles_font-size\":\"\",\"list_item_row_styles_margin\":\"\",\"list_item_row_styles_padding\":\"\",\"list_item_row_styles_float\":\"\",\"list_item_row_styles_show_advanced_css\":0,\"list_item_label_styles_border\":\"\",\"list_item_label_styles_height\":\"\",\"list_item_label_styles_width\":\"\",\"list_item_label_styles_font-size\":\"\",\"list_item_label_styles_margin\":\"\",\"list_item_label_styles_padding\":\"\",\"list_item_label_styles_float\":\"\",\"list_item_label_styles_show_advanced_css\":0,\"list_item_element_styles_border\":\"\",\"list_item_element_styles_height\":\"\",\"list_item_element_styles_width\":\"\",\"list_item_element_styles_font-size\":\"\",\"list_item_element_styles_margin\":\"\",\"list_item_element_styles_padding\":\"\",\"list_item_element_styles_float\":\"\",\"list_item_element_styles_show_advanced_css\":0,\"cellcid\":\"c4609\",\"drawerDisabled\":false,\"field_label\":\"1. Open a tight or new jar\",\"field_key\":\"1_open_a_tight_or_new_jar_1696601523145\",\"id\":767,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"parentType\":\"list\",\"element_templates\":[\"listradio\",\"input\"],\"old_classname\":\"list-radio\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":88,\"idAttribute\":\"id\",\"type\":\"listradio\",\"label\":\"P8. Does performing more ambitious activities like sports, dancing, household chores such as sweeping or putting away dishes increase your problem?\",\"key\":\"p8_does_performing_more_ambitious_activities_like_sports_dancing_household_chores_such_as_sweeping_or_putting_away_dishes_increase_your_problem_1696606000658\",\"label_pos\":\"above\",\"required\":1,\"options\":[{\"errors\":[],\"max_options\":0,\"label\":\"Yes (1)\",\"value\":\"one \",\"calc\":\"\",\"selected\":0,\"order\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"No (2) \",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa 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New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}}],\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"list_item_row_styles_border\":\"\",\"list_item_row_styles_height\":\"\",\"list_item_row_styles_width\":\"\",\"list_item_row_styles_font-size\":\"\",\"list_item_row_styles_margin\":\"\",\"list_item_row_styles_padding\":\"\",\"list_item_row_styles_float\":\"\",\"list_item_row_styles_show_advanced_css\":0,\"list_item_label_styles_border\":\"\",\"list_item_label_styles_height\":\"\",\"list_item_label_styles_width\":\"\",\"list_item_label_styles_font-size\":\"\",\"list_item_label_styles_margin\":\"\",\"list_item_label_styles_padding\":\"\",\"list_item_label_styles_float\":\"\",\"list_item_label_styles_show_advanced_css\":0,\"list_item_element_styles_border\":\"\",\"list_item_element_styles_height\":\"\",\"list_item_element_styles_width\":\"\",\"list_item_element_styles_font-size\":\"\",\"list_item_element_styles_margin\":\"\",\"list_item_element_styles_padding\":\"\",\"list_item_element_styles_float\":\"\",\"list_item_element_styles_show_advanced_css\":0,\"cellcid\":\"c4612\",\"drawerDisabled\":false,\"field_label\":\"1. 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Open a tight or new jar\",\"field_key\":\"1_open_a_tight_or_new_jar_1696601523145\",\"id\":769,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"parentType\":\"list\",\"element_templates\":[\"listradio\",\"input\"],\"old_classname\":\"list-radio\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":90,\"idAttribute\":\"id\",\"type\":\"listradio\",\"label\":\"E10. 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Open a tight or new jar\",\"field_key\":\"1_open_a_tight_or_new_jar_1696601523145\",\"id\":770,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"parentType\":\"list\",\"element_templates\":[\"listradio\",\"input\"],\"old_classname\":\"list-radio\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":91,\"idAttribute\":\"id\",\"type\":\"listradio\",\"label\":\"P11. 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Open a tight or new jar\",\"field_key\":\"1_open_a_tight_or_new_jar_1696601523145\",\"id\":772,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"parentType\":\"list\",\"element_templates\":[\"listradio\",\"input\"],\"old_classname\":\"list-radio\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":93,\"idAttribute\":\"id\",\"type\":\"listradio\",\"label\":\"P13. 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Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"No (2) \",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":2,\"new\":false,\"options\":[],\"label\":\"Sometimes (3)\",\"value\":\"sometimes-3\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons 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Open a tight or new jar\",\"field_key\":\"1_open_a_tight_or_new_jar_1696601523145\",\"id\":773,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"parentType\":\"list\",\"element_templates\":[\"listradio\",\"input\"],\"old_classname\":\"list-radio\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":94,\"idAttribute\":\"id\",\"type\":\"listradio\",\"label\":\"F14. Because of your problem, is it difficult for you to do strenuous housework or yard work? \",\"key\":\"f14_because_of_your_problem_is_it_difficult_for_you_to_do_strenuous_housework_or_yard_work_1696606134428\",\"label_pos\":\"above\",\"required\":1,\"options\":[{\"errors\":[],\"max_options\":0,\"label\":\"Yes (1)\",\"value\":\"one \",\"calc\":\"\",\"selected\":0,\"order\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"No (2) \",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":2,\"new\":false,\"options\":[],\"label\":\"Sometimes (3)\",\"value\":\"sometimes-3\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons 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Open a tight or new jar\",\"field_key\":\"1_open_a_tight_or_new_jar_1696601523145\",\"id\":774,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"parentType\":\"list\",\"element_templates\":[\"listradio\",\"input\"],\"old_classname\":\"list-radio\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":95,\"idAttribute\":\"id\",\"type\":\"listradio\",\"label\":\"E15. Because of your problem, are you afraid people might think you are intoxicated? \",\"key\":\"e15_because_of_your_problem_are_you_afraid_people_might_think_you_are_intoxicated_1696606157725\",\"label_pos\":\"above\",\"required\":1,\"options\":[{\"errors\":[],\"max_options\":0,\"label\":\"Yes (1)\",\"value\":\"one \",\"calc\":\"\",\"selected\":0,\"order\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"No (2) \",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":2,\"new\":false,\"options\":[],\"label\":\"Sometimes (3)\",\"value\":\"sometimes-3\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons 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Open a tight or new jar\",\"field_key\":\"1_open_a_tight_or_new_jar_1696601523145\",\"id\":775,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"parentType\":\"list\",\"element_templates\":[\"listradio\",\"input\"],\"old_classname\":\"list-radio\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":96,\"idAttribute\":\"id\",\"type\":\"listradio\",\"label\":\"F16. Because of your problem, is it difficult for you to go for a walk by yourself? \",\"key\":\"f16_because_of_your_problem_is_it_difficult_for_you_to_go_for_a_walk_by_yourself_1696606180387\",\"label_pos\":\"above\",\"required\":1,\"options\":[{\"errors\":[],\"max_options\":0,\"label\":\"Yes (1)\",\"value\":\"one \",\"calc\":\"\",\"selected\":0,\"order\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> 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Open a tight or new jar\",\"field_key\":\"1_open_a_tight_or_new_jar_1696601523145\",\"id\":777,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"parentType\":\"list\",\"element_templates\":[\"listradio\",\"input\"],\"old_classname\":\"list-radio\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":98,\"idAttribute\":\"id\",\"type\":\"listradio\",\"label\":\"E18. 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New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons 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Open a tight or new jar\",\"field_key\":\"1_open_a_tight_or_new_jar_1696601523145\",\"id\":778,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"parentType\":\"list\",\"element_templates\":[\"listradio\",\"input\"],\"old_classname\":\"list-radio\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":99,\"idAttribute\":\"id\",\"type\":\"listradio\",\"label\":\"F19. 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Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"No (2) \",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":2,\"new\":false,\"options\":[],\"label\":\"Sometimes (3)\",\"value\":\"sometimes-3\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}}],\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"list_item_row_styles_border\":\"\",\"list_item_row_styles_height\":\"\",\"list_item_row_styles_width\":\"\",\"list_item_row_styles_font-size\":\"\",\"list_item_row_styles_margin\":\"\",\"list_item_row_styles_padding\":\"\",\"list_item_row_styles_float\":\"\",\"list_item_row_styles_show_advanced_css\":0,\"list_item_label_styles_border\":\"\",\"list_item_label_styles_height\":\"\",\"list_item_label_styles_width\":\"\",\"list_item_label_styles_font-size\":\"\",\"list_item_label_styles_margin\":\"\",\"list_item_label_styles_padding\":\"\",\"list_item_label_styles_float\":\"\",\"list_item_label_styles_show_advanced_css\":0,\"list_item_element_styles_border\":\"\",\"list_item_element_styles_height\":\"\",\"list_item_element_styles_width\":\"\",\"list_item_element_styles_font-size\":\"\",\"list_item_element_styles_margin\":\"\",\"list_item_element_styles_padding\":\"\",\"list_item_element_styles_float\":\"\",\"list_item_element_styles_show_advanced_css\":0,\"cellcid\":\"c4651\",\"drawerDisabled\":false,\"field_label\":\"1. Open a tight or new jar\",\"field_key\":\"1_open_a_tight_or_new_jar_1696601523145\",\"id\":781,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"parentType\":\"list\",\"element_templates\":[\"listradio\",\"input\"],\"old_classname\":\"list-radio\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":102,\"idAttribute\":\"id\",\"type\":\"listradio\",\"label\":\"E22. Has your problem placed stress on your relationships with members of your family or friends? \",\"key\":\"e22_has_your_problem_placed_stress_on_your_relationships_with_members_of_your_family_or_friends_1696606320867\",\"label_pos\":\"above\",\"required\":1,\"options\":[{\"errors\":[],\"max_options\":0,\"label\":\"Yes (1)\",\"value\":\"one \",\"calc\":\"\",\"selected\":0,\"order\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"No (2) \",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":2,\"new\":false,\"options\":[],\"label\":\"Sometimes (3)\",\"value\":\"sometimes-3\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons 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Open a tight or new jar\",\"field_key\":\"1_open_a_tight_or_new_jar_1696601523145\",\"id\":782,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"parentType\":\"list\",\"element_templates\":[\"listradio\",\"input\"],\"old_classname\":\"list-radio\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":103,\"idAttribute\":\"id\",\"type\":\"listradio\",\"label\":\"E23. Because of your problem, are you depressed? \",\"key\":\"e23_because_of_your_problem_are_you_depressed_1696606335910\",\"label_pos\":\"above\",\"required\":1,\"options\":[{\"errors\":[],\"max_options\":0,\"label\":\"Yes (1)\",\"value\":\"one \",\"calc\":\"\",\"selected\":0,\"order\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"No (2) \",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"order\":2,\"new\":false,\"options\":[],\"label\":\"Sometimes (3)\",\"value\":\"sometimes-3\",\"calc\":\"\",\"selected\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}}}],\"container_class\":\"\",\"element_class\":\"\",\"admin_label\":\"\",\"help_text\":\"\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"list_item_row_styles_border\":\"\",\"list_item_row_styles_height\":\"\",\"list_item_row_styles_width\":\"\",\"list_item_row_styles_font-size\":\"\",\"list_item_row_styles_margin\":\"\",\"list_item_row_styles_padding\":\"\",\"list_item_row_styles_float\":\"\",\"list_item_row_styles_show_advanced_css\":0,\"list_item_label_styles_border\":\"\",\"list_item_label_styles_height\":\"\",\"list_item_label_styles_width\":\"\",\"list_item_label_styles_font-size\":\"\",\"list_item_label_styles_margin\":\"\",\"list_item_label_styles_padding\":\"\",\"list_item_label_styles_float\":\"\",\"list_item_label_styles_show_advanced_css\":0,\"list_item_element_styles_border\":\"\",\"list_item_element_styles_height\":\"\",\"list_item_element_styles_width\":\"\",\"list_item_element_styles_font-size\":\"\",\"list_item_element_styles_margin\":\"\",\"list_item_element_styles_padding\":\"\",\"list_item_element_styles_float\":\"\",\"list_item_element_styles_show_advanced_css\":0,\"cellcid\":\"c4657\",\"drawerDisabled\":false,\"field_label\":\"1. Open a tight or new jar\",\"field_key\":\"1_open_a_tight_or_new_jar_1696601523145\",\"id\":783,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"\",\"parentType\":\"list\",\"element_templates\":[\"listradio\",\"input\"],\"old_classname\":\"list-radio\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":104,\"idAttribute\":\"id\",\"type\":\"listradio\",\"label\":\"F24. Does your problem interfere with your job or household responsibilities? \",\"key\":\"f24_does_your_problem_interfere_with_your_job_or_household_responsibilities_1696606356781\",\"label_pos\":\"above\",\"required\":1,\"options\":[{\"errors\":[],\"max_options\":0,\"label\":\"Yes (1)\",\"value\":\"one \",\"calc\":\"\",\"selected\":0,\"order\":0,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa fa-sign-in\\\" aria-hidden=\\\"true\\\"><\\\/i> Import<\\\/a>\",\"width\":\"full\",\"group\":\"\",\"value\":[{\"label\":\"One\",\"value\":\"one\",\"calc\":\"\",\"selected\":0,\"order\":0},{\"label\":\"Two\",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1},{\"label\":\"Three\",\"value\":\"three\",\"calc\":\"\",\"selected\":0,\"order\":2}],\"columns\":{\"label\":{\"header\":\"Label\",\"default\":\"\"},\"value\":{\"header\":\"Value\",\"default\":\"\"},\"calc\":{\"header\":\"Calc Value\",\"default\":\"\"},\"selected\":{\"header\":\"<span class=\\\"dashicons dashicons-yes\\\"><\\\/span>\",\"default\":0}}},\"manual_value\":true},{\"errors\":[],\"max_options\":0,\"label\":\"No (2) \",\"value\":\"two\",\"calc\":\"\",\"selected\":0,\"order\":1,\"settingModel\":{\"settings\":false,\"hide_merge_tags\":false,\"error\":false,\"name\":\"options\",\"type\":\"option-repeater\",\"label\":\"Options <a href=\\\"#\\\" class=\\\"nf-add-new\\\">Add New<\\\/a> <a href=\\\"#\\\" class=\\\"extra nf-open-import-tooltip\\\"><i class=\\\"fa 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CONSENT FOR TREATMENT: <\\\/b>I consent to and authorize my physical therapist and other healthcare professionals and assistants who may be involved in my care, to provide care and treatment prescribed by and\\\/or considered necessary or advisable by my physicians(s)\\\/health care providers(s). I acknowledge that no guarantees have been made to me about the results of treatment.<\\\/p><p><b>2. APPOINTMENT ATTENDANCE AGREEMENT: <\\\/b>I understand the importance of attending therapy consistently and arriving promptly for my appointment. I acknowledge that I may be rescheduled if I arrive more than 15 minutes late for my scheduled appointment. I understand the importance of scheduling appointments in advance and acknowledge that appointment times given one week do not automatically follow through to subsequent weeks. I agree to provide at least a 24 hours or not showing up for an appointment will likely result in a cancel\\\/no show charge of $50.<\\\/p><p><b>WORKER'S COMPENSATION PATIENTS: <\\\/b>We appreciate your full cooperation in attending all scheduled therapy sessions. We are required to inform your Worker's Compensation Adjuster and\\\/or Rehabilitation Manager of all missed or cancelled appointments. It is also required that all missed visits to be rescheduled.<\\\/p><p><b>3. RESPONSIBILITY FOR PAYMENT: <\\\/b>All co-payments are due at the time of service. I acknowledge that in consideration of the services provided to me by Metamora PT, I am financially responsible for payment of my bill. I acknowledge that it is my responsibility to provide Metamora PT with current insurance information and to familiarize myself with my insurance plan and its policies. Any questions I have regarding my health insurance coverage or benefit levels should be directed to my health plan. My health insurance plan may provide that a portion of the charges and balance will remain my personal responsibility, such as my deductible, co-payment, co-insurance or charges not covered or denied by my health insurance, Medicare, or other programs for which I am eligible. When you provide a check as payment in the clinic, you authorize us to use the information from your check to process a one-time Electronic Funds Transfer (EFT\\\/ACH) or a draft drawn from your check to make an EFT, funds may be withdrawn from your account as soon as the same day and you will not receive your check back from your financial institution.<\\\/p><p><i>Please note that refusal to sign this form does not change responsibility for payment in anyway.<\\\/i><\\\/p><p><b>4. ASSIGNMENT OF BENEFITS: <\\\/b>I hereby assign to Metamora PT all my rights and claims for reimbursement under my health insurance policy. I agree to provide information as needed to establish my eligibility for such benefits.<\\\/p><p><b>5. ACCESS TO AND RELEASE OF HEALTH INFORMATION:&nbsp; <\\\/b>I understand that Metamora PT may document medical and other information related to my treatment in electronic and other forms and that such information will be used in the course of my treatment, for payment purposes and to support those who are caring for me. I authorize my clinician(s) and Metamora PT's administrative staff to contact other healthcare professionals that may have information related to my prior and current health conditions and treatments. I acknowledge that I have received Metamora PT's Notice or Privacy Practices and that it outlines how my health information will be used and disclosed and how I may gain access to and control my health information.&nbsp;<\\\/p><p><b>6. HIPAA CONSENTS: <\\\/b>In compliance with HIPAA regulations, I give consent to the following individuals to receive verbal information regarding the billing and scheduling of my account:&nbsp;<\\\/p>\",\"id\":722,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"<p style=\\\"text-align: center; \\\"><b><u>CONSENT FOR TREATMENT<\\\/u><\\\/b><\\\/p><p><b>1. CONSENT FOR TREATMENT: <\\\/b>I consent to and authorize my physical therapist and other healthcare professionals and assistants who may be involved in my care, to provide care and treatment prescribed by and\\\/or considered necessary or advisable by my physicians(s)\\\/health care providers(s). I acknowledge that no guarantees have been made to me about the results of treatment.<\\\/p><p><b>2. APPOINTMENT ATTENDANCE AGREEMENT: <\\\/b>I understand the importance of attending therapy consistently and arriving promptly for my appointment. I acknowledge that I may be rescheduled if I arrive more than 15 minutes late for my scheduled appointment. I understand the importance of scheduling appointments in advance and acknowledge that appointment times given one week do not automatically follow through to subsequent weeks. I agree to provide at least a 24 hours or not showing up for an appointment will likely result in a cancel\\\/no show charge of $50.<\\\/p><p><b>WORKER'S COMPENSATION PATIENTS: <\\\/b>We appreciate your full cooperation in attending all scheduled therapy sessions. We are required to inform your Worker's Compensation Adjuster and\\\/or Rehabilitation Manager of all missed or cancelled appointments. It is also required that all missed visits to be rescheduled.<\\\/p><p><b>3. RESPONSIBILITY FOR PAYMENT: <\\\/b>All co-payments are due at the time of service. I acknowledge that in consideration of the services provided to me by Metamora PT, I am financially responsible for payment of my bill. I acknowledge that it is my responsibility to provide Metamora PT with current insurance information and to familiarize myself with my insurance plan and its policies. Any questions I have regarding my health insurance coverage or benefit levels should be directed to my health plan. My health insurance plan may provide that a portion of the charges and balance will remain my personal responsibility, such as my deductible, co-payment, co-insurance or charges not covered or denied by my health insurance, Medicare, or other programs for which I am eligible. When you provide a check as payment in the clinic, you authorize us to use the information from your check to process a one-time Electronic Funds Transfer (EFT\\\/ACH) or a draft drawn from your check to make an EFT, funds may be withdrawn from your account as soon as the same day and you will not receive your check back from your financial institution.<\\\/p><p><i>Please note that refusal to sign this form does not change responsibility for payment in anyway.<\\\/i><\\\/p><p><b>4. ASSIGNMENT OF BENEFITS: <\\\/b>I hereby assign to Metamora PT all my rights and claims for reimbursement under my health insurance policy. I agree to provide information as needed to establish my eligibility for such benefits.<\\\/p><p><b>5. ACCESS TO AND RELEASE OF HEALTH INFORMATION:&nbsp; <\\\/b>I understand that Metamora PT may document medical and other information related to my treatment in electronic and other forms and that such information will be used in the course of my treatment, for payment purposes and to support those who are caring for me. I authorize my clinician(s) and Metamora PT's administrative staff to contact other healthcare professionals that may have information related to my prior and current health conditions and treatments. I acknowledge that I have received Metamora PT's Notice or Privacy Practices and that it outlines how my health information will be used and disclosed and how I may gain access to and control my health information.&nbsp;<\\\/p><p><b>6. HIPAA CONSENTS: <\\\/b>In compliance with HIPAA regulations, I give consent to the following individuals to receive verbal information regarding the billing and scheduling of my account:&nbsp;<\\\/p>\",\"label_pos\":\"above\",\"parentType\":\"html\",\"element_templates\":[\"html\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":112,\"idAttribute\":\"id\",\"label\":\"Name\\\/Relationship\",\"type\":\"textbox\",\"key\":\"name_relationship_1696516365146\",\"label_pos\":\"above\",\"required\":1,\"default\":\"\",\"placeholder\":\"\",\"container_class\":\"\",\"element_class\":\"\",\"input_limit\":\"\",\"input_limit_type\":\"characters\",\"input_limit_msg\":\"Character(s) 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for treatment (cont.)\",\"type\":\"html\",\"default\":\"<p>I also authorize the release of appointment information left in a voice-mail, answering machine or text message and understand that there is some level of privacy risk associated with these forms of communication.<\\\/p><p><b>7. CONSENT FOR EMERGENCY CONTACT INFORMATION: <\\\/b>Person to contact in case of an emergency:<\\\/p>\",\"container_class\":\"\",\"element_class\":\"\",\"wrap_styles_border\":\"\",\"wrap_styles_width\":\"\",\"wrap_styles_margin\":\"\",\"wrap_styles_padding\":\"\",\"wrap_styles_float\":\"\",\"wrap_styles_show_advanced_css\":0,\"label_styles_border\":\"\",\"label_styles_width\":\"\",\"label_styles_font-size\":\"\",\"label_styles_margin\":\"\",\"label_styles_padding\":\"\",\"label_styles_float\":\"\",\"label_styles_show_advanced_css\":0,\"element_styles_border\":\"\",\"element_styles_width\":\"\",\"element_styles_font-size\":\"\",\"element_styles_margin\":\"\",\"element_styles_padding\":\"\",\"element_styles_float\":\"\",\"element_styles_show_advanced_css\":0,\"key\":\"consent_for_treatment_cont_1696516404482\",\"cellcid\":\"c4693\",\"drawerDisabled\":\"\",\"field_label\":\"Consent for treatment (cont.)\",\"field_key\":\"consent_for_treatment_cont_1696516404482\",\"id\":726,\"beforeField\":\"\",\"afterField\":\"\",\"value\":\"<p>I also authorize the release of appointment information left in a voice-mail, answering machine or text message and understand that there is some level of privacy risk associated with these forms of communication.<\\\/p><p><b>7. CONSENT FOR EMERGENCY CONTACT INFORMATION: <\\\/b>Person to contact in case of an emergency:<\\\/p>\",\"label_pos\":\"above\",\"parentType\":\"html\",\"element_templates\":[\"html\",\"input\"],\"old_classname\":\"\",\"wrap_template\":\"wrap\"},{\"objectType\":\"Field\",\"objectDomain\":\"fields\",\"editActive\":false,\"order\":116,\"idAttribute\":\"id\",\"label\":\"Name\",\"type\":\"textbox\",\"key\":\"name_1696516495754\",\"label_pos\":\"above\",\"required\":1,\"default\":\"\",\"placeholder\":\"\",\"container_class\":\"\",\"element_class\":\"\",\"input_limit\":\"\",\"input_limit_type\":\"characters\",\"input_limit_msg\":\"Character(s) 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style=\\\"font-weight: 600;\\\"><u>NOTICE OF PATIENT INFORMATION PRACTICES<\\\/u><\\\/span><\\\/p><p style=\\\"text-align: center;\\\">THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO INFORMATION. PLEASE REVIEW IT CAREFULLY.<\\\/p><p style=\\\"text-align: center;\\\"><span style=\\\"font-weight: 600;\\\">Metamora Physical Therapy, LLC's LEGAL DUTY<\\\/span><\\\/p><p>Metamora Physical Therapy, LLC uses your personal health information primarily for treatment' obtaining payment for treatment; conducting internal administrative activities and evaluating the quality of care that we provide. For example, Metamora Physical Therapy, LLC may use your personal health information to contact you to provide appointment reminds, or information about treatment alternatives or other health related benefits that could be of interest to you.<\\\/p><p>Metamora Physical Therapy, LLC may also use your or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, for research studies and for emergencies. We also provide information when required by law.<\\\/p><p>In any other situation, Metamora Physical Therapy, LLC's policy is to obtain your written authorization before disclosing your personal health information. If you provide us with a written authorization to release your information for any reason, you may later revoke that authorization to stop future disclosures at any time.&nbsp;<\\\/p><p><span style=\\\"font-weight: 600;\\\">PATIENT'S INDIVIDUAL RIGHTS<\\\/span><\\\/p><p>You have the right to review or obtain a copy of your personal health information at any time. You have the right to request that we correct any inaccurate or incomplete information in your records. You also have the right to request a list of instances where we have disclosed your personal health information for reasons other than treatment, payment or other related administrative purposes.&nbsp;<\\\/p><p>You may also request in writing that we not use or disclose your personal health information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law or in emergency circumstances. Metamora Physical Therapy, LLC will consider all such requests on a case by case basis, but the practice is not legally required to accept them.&nbsp;<\\\/p><p><span style=\\\"font-weight: 600;\\\">CONCERNS AND COMPLAINTS&nbsp;<\\\/span><\\\/p><p>If you are concerned that Metamora Physical Therapy, LLC may have violated your privacy rights or if you disagree with any decisions we have made regarding access or disclosure of your personal health information, please contact our practice manager at the address listed below. 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You also have the right to request a list of instances where we have disclosed your personal health information for reasons other than treatment, payment or other related administrative purposes.&nbsp;<\\\/p><p>You may also request in writing that we not use or disclose your personal health information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law or in emergency circumstances. Metamora Physical Therapy, LLC will consider all such requests on a case by case basis, but the practice is not legally required to accept them.&nbsp;<\\\/p><p><span style=\\\"font-weight: 600;\\\">CONCERNS AND COMPLAINTS&nbsp;<\\\/span><\\\/p><p>If you are concerned that Metamora Physical Therapy, LLC may have violated your privacy rights or if you disagree with any decisions we have made regarding access or disclosure of your personal health information, please contact our practice manager at the address listed below. 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