{"id":3387,"date":"2026-05-18T19:07:28","date_gmt":"2026-05-18T19:07:28","guid":{"rendered":"https:\/\/rhinowebllc.com\/magnolia-disability-law-firm\/?page_id=3387"},"modified":"2026-05-18T19:12:58","modified_gmt":"2026-05-18T19:12:58","slug":"ce-form","status":"publish","type":"page","link":"https:\/\/rhinowebllc.com\/magnolia-disability-law-firm\/ce-form\/","title":{"rendered":"Consultative Examination (CE) Feedback Form"},"content":{"rendered":"<p><section data-bb-version=\"5.7.2\" id=\"bt_bb_section6a0c5cd1868f0\" class=\"bt_bb_section bt_bb_color_scheme_11 bt_bb_layout_boxed_1400 bt_bb_vertical_align_top bt_bb_background_overlay_alternate_solid bt_bb_bottom_section_coverage_image bt_bb_section_with_bottom_coverage_image bt_bb_top_spacing_large bt_bb_bottom_spacing_large bt_bb_negative_margin_none\" style=\"; --section-primary-color:var(--light-color); --section-secondary-color:var(--transparent-color);\" data-bt-override-class=\"{&quot;bt_bb_top_spacing_&quot;:{&quot;current_class&quot;:&quot;bt_bb_top_spacing_large&quot;,&quot;def&quot;:&quot;large&quot;},&quot;bt_bb_bottom_spacing_&quot;:{&quot;current_class&quot;:&quot;bt_bb_bottom_spacing_large&quot;,&quot;def&quot;:&quot;large&quot;},&quot;bt_bb_negative_margin_&quot;:{&quot;current_class&quot;:&quot;bt_bb_negative_margin_none&quot;,&quot;def&quot;:&quot;none&quot;}}\"><div class=\"bt_bb_background_image_holder_wrapper\"><div class=\"bt_bb_background_image_holder btLazyLoadBackground bt_bb_parallax\"  data-background_image_src=\"https:\/\/rhinowebllc.com\/magnolia-disability-law-firm\/wp-content\/uploads\/2024\/04\/hero_single_service.jpg\" data-parallax=\"0.6\" data-parallax-offset=\"0\" data-parallax-zoom-start=\"1\" data-parallax-zoom-end=\"1\" data-parallax-blur-start=\"0\" data-parallax-blur-end=\"2\" data-parallax-opacity-start=\"1\" data-parallax-opacity-end=\"1\" style=\" background-image: url(&#039;https:\/\/rhinowebllc.com\/magnolia-disability-law-firm\/wp-content\/plugins\/bold-page-builder\/img\/blank.gif&#039;);\"><\/div><\/div><div class=\"bt_bb_port\"><div class=\"bt_bb_cell\"><div class=\"bt_bb_cell_inner\"><div class=\"bt_bb_row \"  data-bt-override-class=\"{}\"><div class=\"bt_bb_row_holder\" ><div data-bb-version=\"4.9.1\"  class=\"bt_bb_column col-xxl-12 col-xl-12 col-xs-12 col-sm-12 col-md-12 col-lg-12 bt_bb_vertical_align_middle bt_bb_align_left bt_bb_padding_normal bt_bb_animation_fade_in animate\" style=\"; --column-width:12;\" data-width=\"12\" data-bt-override-class=\"{&quot;bt_bb_align_&quot;:{&quot;current_class&quot;:&quot;bt_bb_align_left&quot;,&quot;def&quot;:&quot;left&quot;,&quot;sm&quot;:&quot;center&quot;,&quot;xs&quot;:&quot;center&quot;},&quot;bt_bb_padding_&quot;:{&quot;current_class&quot;:&quot;bt_bb_padding_normal&quot;,&quot;def&quot;:&quot;normal&quot;}}\"><div class=\"bt_bb_column_content\"><div class=\"bt_bb_column_content_inner\"><div data-bb-version=\"4.9.1\" class=\"bt_bb_separator_v2 bt_bb_border_style_none bt_bb_top_spacing_medium bt_bb_bottom_spacing_large bt_bb_border_thickness_1 bt_bb_icon_size_normal bt_bb_text_size_normal bt_bb_separator_v2_without_content\" data-bt-override-class=\"{&quot;bt_bb_top_spacing_&quot;:{&quot;current_class&quot;:&quot;bt_bb_top_spacing_medium&quot;,&quot;def&quot;:&quot;medium&quot;},&quot;bt_bb_bottom_spacing_&quot;:{&quot;current_class&quot;:&quot;bt_bb_bottom_spacing_large&quot;,&quot;def&quot;:&quot;large&quot;},&quot;bt_bb_border_thickness_&quot;:{&quot;current_class&quot;:&quot;bt_bb_border_thickness_1&quot;,&quot;def&quot;:&quot;1&quot;},&quot;bt_bb_icon_size_&quot;:{&quot;current_class&quot;:&quot;bt_bb_icon_size_normal&quot;,&quot;def&quot;:&quot;normal&quot;},&quot;bt_bb_text_size_&quot;:{&quot;current_class&quot;:&quot;bt_bb_text_size_normal&quot;,&quot;def&quot;:&quot;normal&quot;}}\"><div class=\"bt_bb_separator_v2_inner\"><span class=\"bt_bb_separator_v2_inner_before\"><\/span><span class=\"bt_bb_separator_v2_inner_content\"><span  data-ico-=\"\" class=\"bt_bb_icon_holder\"><\/span><\/span><span class=\"bt_bb_separator_v2_inner_after\"><\/span><\/div><\/div><header data-bb-version=\"5.8.0\" class=\"bt_bb_headline bt_bb_dash_none bt_bb_size_large bt_bb_align_inherit bt_bb_wrap_yes bt_bb_subtitle_color_gray_02\" data-bt-override-class=\"{&quot;bt_bb_size_&quot;:{&quot;current_class&quot;:&quot;bt_bb_size_large&quot;,&quot;def&quot;:&quot;large&quot;},&quot;bt_bb_align_&quot;:{&quot;current_class&quot;:&quot;bt_bb_align_inherit&quot;,&quot;def&quot;:&quot;inherit&quot;},&quot;bt_bb_wrap_&quot;:{&quot;current_class&quot;:&quot;bt_bb_wrap_yes&quot;,&quot;def&quot;:&quot;yes&quot;},&quot;bt_bb_animation_&quot;:{&quot;current_class&quot;:&quot;bt_bb_animation_no_animation&quot;,&quot;def&quot;:&quot;no_animation&quot;}}\"><h1 class=\"bt_bb_headline_tag\"><span class=\"bt_bb_headline_content\"><span>Consultative Examination (CE) Feedback Form<\/span><\/span><\/h1><\/header><\/div><\/div><\/div><\/div><\/div><\/div><!-- cell_inner --><\/div><!-- cell --><\/div><!-- port --><div class=\"bt_bb_section_bottom_section_coverage_image\"><img decoding=\"async\" src=\"https:\/\/rhinowebllc.com\/magnolia-disability-law-firm\/wp-content\/uploads\/2024\/04\/bottom_grey_01.png\" alt=\"bt_bb_section_bottom_section_coverage_image\" \/><\/div><\/section><section data-bb-version=\"5.8.0\" id=\"bt_bb_section6a0c5cd186c73\" class=\"bt_bb_section bt_bb_color_scheme_21 bt_bb_layout_boxed_1400 bt_bb_vertical_align_top bt_bb_top_spacing_large bt_bb_bottom_spacing_large bt_bb_negative_margin_none bt_bb_top_left_shape_none bt_bb_top_right_shape_none bt_bb_bottom_left_shape_none bt_bb_bottom_right_shape_none bt_bb_negative_margin_none bt_bb_top_left_shape_none bt_bb_top_right_shape_none bt_bb_bottom_left_shape_none bt_bb_bottom_right_shape_none\" style=\"; --section-primary-color:var(--gray-04-color); --section-secondary-color:var(--transparent-color);;background-color:rgb(249,248,246);\" data-bt-override-class=\"{&quot;bt_bb_top_spacing_&quot;:{&quot;current_class&quot;:&quot;bt_bb_top_spacing_large&quot;,&quot;def&quot;:&quot;large&quot;},&quot;bt_bb_bottom_spacing_&quot;:{&quot;current_class&quot;:&quot;bt_bb_bottom_spacing_large&quot;,&quot;def&quot;:&quot;large&quot;},&quot;bt_bb_negative_margin_&quot;:{&quot;current_class&quot;:&quot;bt_bb_negative_margin_none&quot;,&quot;def&quot;:&quot;none&quot;},&quot;bt_bb_top_left_shape_&quot;:{&quot;current_class&quot;:&quot;bt_bb_top_left_shape_none&quot;,&quot;def&quot;:&quot;none&quot;},&quot;bt_bb_top_right_shape_&quot;:{&quot;current_class&quot;:&quot;bt_bb_top_right_shape_none&quot;,&quot;def&quot;:&quot;none&quot;},&quot;bt_bb_bottom_left_shape_&quot;:{&quot;current_class&quot;:&quot;bt_bb_bottom_left_shape_none&quot;,&quot;def&quot;:&quot;none&quot;},&quot;bt_bb_bottom_right_shape_&quot;:{&quot;current_class&quot;:&quot;bt_bb_bottom_right_shape_none&quot;,&quot;def&quot;:&quot;none&quot;},&quot;bt_bb_animation_&quot;:{&quot;current_class&quot;:&quot;bt_bb_animation_no_animation&quot;,&quot;def&quot;:&quot;no_animation&quot;}}\"><div class=\"bt_bb_port\"><div class=\"bt_bb_cell\"><div class=\"bt_bb_cell_inner\"><div class=\"bt_bb_row \"  data-bt-override-class=\"{}\"><div class=\"bt_bb_row_holder\" ><div data-bb-version=\"5.0.5\"  class=\"bt_bb_column col-xxl-12 col-xl-12 col-xs-12 col-sm-12 col-md-12 col-lg-12 bt_bb_vertical_align_top bt_bb_align_left bt_bb_padding_none bt_bb_border_top_none bt_bb_border_bottom_none bt_bb_border_right_none bt_bb_border_left_none bt_bb_animation_fade_in animate bt_bb_border_top_none bt_bb_border_bottom_none bt_bb_border_right_none bt_bb_border_left_none bt_bb_border_thickness_1px bt_bb_border_color_gray_01\" style=\"; --column-width:12;\" data-width=\"12\" data-bt-override-class=\"{&quot;bt_bb_align_&quot;:{&quot;current_class&quot;:&quot;bt_bb_align_left&quot;,&quot;def&quot;:&quot;left&quot;,&quot;md&quot;:&quot;center&quot;,&quot;sm&quot;:&quot;center&quot;,&quot;xs&quot;:&quot;center&quot;},&quot;bt_bb_padding_&quot;:{&quot;current_class&quot;:&quot;bt_bb_padding_none&quot;,&quot;def&quot;:&quot;none&quot;},&quot;bt_bb_border_top_&quot;:{&quot;current_class&quot;:&quot;bt_bb_border_top_none&quot;,&quot;def&quot;:&quot;none&quot;},&quot;bt_bb_border_bottom_&quot;:{&quot;current_class&quot;:&quot;bt_bb_border_bottom_none&quot;,&quot;def&quot;:&quot;none&quot;},&quot;bt_bb_border_right_&quot;:{&quot;current_class&quot;:&quot;bt_bb_border_right_none&quot;,&quot;def&quot;:&quot;none&quot;},&quot;bt_bb_border_left_&quot;:{&quot;current_class&quot;:&quot;bt_bb_border_left_none&quot;,&quot;def&quot;:&quot;none&quot;}}\"><div class=\"bt_bb_column_content\"><div class=\"bt_bb_column_content_inner\"><header data-bb-version=\"5.8.0\" class=\"bt_bb_headline bt_bb_color_scheme_4 bt_bb_dash_none bt_bb_size_medium bt_bb_align_inherit bt_bb_wrap_yes bt_bb_wrap_yes bt_bb_supertitle_color_gray_03 bt_bb_subtitle_color_gray_04\" style=\"; --primary-color:var(--dark-color); --secondary-color:var(--accent-color);\" data-bt-override-class=\"{&quot;bt_bb_size_&quot;:{&quot;current_class&quot;:&quot;bt_bb_size_medium&quot;,&quot;def&quot;:&quot;medium&quot;},&quot;bt_bb_align_&quot;:{&quot;current_class&quot;:&quot;bt_bb_align_inherit&quot;,&quot;def&quot;:&quot;inherit&quot;},&quot;bt_bb_wrap_&quot;:{&quot;current_class&quot;:&quot;bt_bb_wrap_yes&quot;,&quot;def&quot;:&quot;yes&quot;},&quot;bt_bb_animation_&quot;:{&quot;current_class&quot;:&quot;bt_bb_animation_no_animation&quot;,&quot;def&quot;:&quot;no_animation&quot;}}\"><h2 class=\"bt_bb_headline_tag\"><span class=\"bt_bb_headline_content\"><span>Please fill-out the CE  form<\/span><\/span><\/h2><\/header><div data-bb-version=\"5.7.2\" class=\"bt_bb_separator_v2 bt_bb_border_style_none bt_bb_top_spacing_none bt_bb_bottom_spacing_normal bt_bb_border_thickness_1 bt_bb_icon_size_normal bt_bb_text_size_normal bt_bb_separator_v2_without_content\" data-bt-override-class=\"{&quot;bt_bb_top_spacing_&quot;:{&quot;current_class&quot;:&quot;bt_bb_top_spacing_none&quot;,&quot;def&quot;:&quot;none&quot;},&quot;bt_bb_bottom_spacing_&quot;:{&quot;current_class&quot;:&quot;bt_bb_bottom_spacing_normal&quot;,&quot;def&quot;:&quot;normal&quot;},&quot;bt_bb_border_thickness_&quot;:{&quot;current_class&quot;:&quot;bt_bb_border_thickness_1&quot;,&quot;def&quot;:&quot;1&quot;},&quot;bt_bb_icon_size_&quot;:{&quot;current_class&quot;:&quot;bt_bb_icon_size_normal&quot;,&quot;def&quot;:&quot;normal&quot;},&quot;bt_bb_text_size_&quot;:{&quot;current_class&quot;:&quot;bt_bb_text_size_normal&quot;,&quot;def&quot;:&quot;normal&quot;},&quot;bt_bb_animation_&quot;:{&quot;current_class&quot;:&quot;bt_bb_animation_no_animation&quot;,&quot;def&quot;:&quot;no_animation&quot;}}\"><div class=\"bt_bb_separator_v2_inner\"><span class=\"bt_bb_separator_v2_inner_before\"><\/span><span class=\"bt_bb_separator_v2_inner_content\"><span  data-ico-=\"\" class=\"bt_bb_icon_holder\"><\/span><\/span><span class=\"bt_bb_separator_v2_inner_after\"><\/span><\/div><\/div><div data-bb-version=\"5.7.2\"  class=\"bt_bb_text\" ><\/p>\n<p>Your appointment with the Social Security doctor is over\u2014now it\u2019s our turn to review how it went. The SSA doctors are supposed to conduct fair, thorough exams, but unfortunately, they sometimes rush or omit critical details. Please take 3 minutes to fill out this form while the experience is fresh in your mind. Your answers will help David and your legal team prepare for your hearing.<\/p>\n<p>\n<\/div><div data-bb-version=\"5.7.2\" class=\"bt_bb_separator_v2 bt_bb_border_style_none bt_bb_top_spacing_none bt_bb_bottom_spacing_normal bt_bb_border_thickness_1 bt_bb_icon_size_normal bt_bb_text_size_normal bt_bb_separator_v2_without_content\" 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#112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/magnolia-disability-law-firm\/wp-json\/wp\/v2\/pages\/3387' data-formid='1' novalidate>\r\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_1_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_4'>Full Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_1_4' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_5\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_5'>Date of Exam<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\r\n                            <input name='input_5' id='input_1_5' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_5_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\r\n                            <span id='input_1_5_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\r\n                        <\/div>\r\n                        <input type='hidden' id='gforms_calendar_icon_input_1_5' class='gform_hidden' value='https:\/\/rhinowebllc.com\/magnolia-disability-law-firm\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_1_17\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >What time did the doctor actually sit down with you?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_17'>\r\n\t\t\t<div class='gchoice gchoice_1_17_0'>\r\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='AM'  id='choice_1_17_0' onchange='gformToggleRadioOther( this )'    \/>\r\n\t\t\t\t\t<label for='choice_1_17_0' id='label_1_17_0' class='gform-field-label gform-field-label--type-inline'>AM<\/label>\r\n\t\t\t<\/div>\r\n\t\t\t<div class='gchoice gchoice_1_17_1'>\r\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='PM'  id='choice_1_17_1' onchange='gformToggleRadioOther( this )'    \/>\r\n\t\t\t\t\t<label for='choice_1_17_1' id='label_1_17_1' class='gform-field-label gform-field-label--type-inline'>PM<\/label>\r\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_18\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >What time did the exam end?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_18'>\r\n\t\t\t<div class='gchoice gchoice_1_18_0'>\r\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='AM'  id='choice_1_18_0' onchange='gformToggleRadioOther( this )'    \/>\r\n\t\t\t\t\t<label for='choice_1_18_0' id='label_1_18_0' class='gform-field-label gform-field-label--type-inline'>AM<\/label>\r\n\t\t\t<\/div>\r\n\t\t\t<div class='gchoice gchoice_1_18_1'>\r\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='PM'  id='choice_1_18_1' onchange='gformToggleRadioOther( this )'    \/>\r\n\t\t\t\t\t<label for='choice_1_18_1' id='label_1_18_1' class='gform-field-label gform-field-label--type-inline'>PM<\/label>\r\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_9\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_9'>What type of exam did you attend today?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_9' id='input_1_9' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please Select<\/option><option value='Physical Exam' >Physical Exam<\/option><option value='Mental \/ Psychological Exam' >Mental \/ Psychological Exam<\/option><\/select><\/div><\/div><fieldset id=\"field_1_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did the doctor physically touch or examine your problem areas?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_10'>\r\n\t\t\t<div class='gchoice gchoice_1_10_0'>\r\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Yes'  id='choice_1_10_0' onchange='gformToggleRadioOther( this )'    \/>\r\n\t\t\t\t\t<label for='choice_1_10_0' id='label_1_10_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\r\n\t\t\t<\/div>\r\n\t\t\t<div class='gchoice gchoice_1_10_1'>\r\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='No'  id='choice_1_10_1' onchange='gformToggleRadioOther( this )'    \/>\r\n\t\t\t\t\t<label for='choice_1_10_1' id='label_1_10_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\r\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did the doctor measure your range of motion (e.g., using a tool to see how far you can bend your back, lift your arms, or turn your neck)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_11'>\r\n\t\t\t<div class='gchoice gchoice_1_11_0'>\r\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Yes'  id='choice_1_11_0' onchange='gformToggleRadioOther( this )'    \/>\r\n\t\t\t\t\t<label for='choice_1_11_0' id='label_1_11_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\r\n\t\t\t<\/div>\r\n\t\t\t<div class='gchoice gchoice_1_11_1'>\r\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='No'  id='choice_1_11_1' onchange='gformToggleRadioOther( this )'    \/>\r\n\t\t\t\t\t<label for='choice_1_11_1' id='label_1_11_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\r\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_13\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_2col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Did the doctor ask you to perform physical tests? (Check all that applied)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_13'><div class='gchoice gchoice_1_13_1'>\r\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.1' type='checkbox'  value='Walk down the hall'  id='choice_1_13_1'   \/>\r\n\t\t\t\t\t\t\t\t<label for='choice_1_13_1' id='label_1_13_1' class='gform-field-label gform-field-label--type-inline'>Walk down the hall<\/label>\r\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_2'>\r\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.2' type='checkbox'  value='Squat and stand back up'  id='choice_1_13_2'   \/>\r\n\t\t\t\t\t\t\t\t<label for='choice_1_13_2' id='label_1_13_2' class='gform-field-label gform-field-label--type-inline'>Squat and stand back up<\/label>\r\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_3'>\r\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.3' type='checkbox'  value='Bend over to touch your toes'  id='choice_1_13_3'   \/>\r\n\t\t\t\t\t\t\t\t<label for='choice_1_13_3' id='label_1_13_3' class='gform-field-label gform-field-label--type-inline'>Bend over to touch your toes<\/label>\r\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_4'>\r\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.4' type='checkbox'  value='Grip the doctor&#039;s hands\/fingers'  id='choice_1_13_4'   \/>\r\n\t\t\t\t\t\t\t\t<label for='choice_1_13_4' id='label_1_13_4' class='gform-field-label gform-field-label--type-inline'>Grip the doctor's hands\/fingers<\/label>\r\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_5'>\r\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.5' type='checkbox'  value='Stand on one leg'  id='choice_1_13_5'   \/>\r\n\t\t\t\t\t\t\t\t<label for='choice_1_13_5' id='label_1_13_5' class='gform-field-label gform-field-label--type-inline'>Stand on one leg<\/label>\r\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_6'>\r\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.6' type='checkbox'  value='None of the above'  id='choice_1_13_6'   \/>\r\n\t\t\t\t\t\t\t\t<label for='choice_1_13_6' id='label_1_13_6' class='gform-field-label gform-field-label--type-inline'>None of the above<\/label>\r\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_14\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did you use a cane, walker, or brace during the exam?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_14'>\r\n\t\t\t<div class='gchoice gchoice_1_14_0'>\r\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Yes'  id='choice_1_14_0' onchange='gformToggleRadioOther( this )'    \/>\r\n\t\t\t\t\t<label for='choice_1_14_0' id='label_1_14_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\r\n\t\t\t<\/div>\r\n\t\t\t<div class='gchoice gchoice_1_14_1'>\r\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='No'  id='choice_1_14_1' onchange='gformToggleRadioOther( this )'    \/>\r\n\t\t\t\t\t<label for='choice_1_14_1' id='label_1_14_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\r\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_16\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did the doctor ask if it was prescribed or how long you&#039;ve used it?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_16'>\r\n\t\t\t<div class='gchoice gchoice_1_16_0'>\r\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Yes'  id='choice_1_16_0' onchange='gformToggleRadioOther( this )'    \/>\r\n\t\t\t\t\t<label for='choice_1_16_0' id='label_1_16_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\r\n\t\t\t<\/div>\r\n\t\t\t<div class='gchoice gchoice_1_16_1'>\r\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='No'  id='choice_1_16_1' onchange='gformToggleRadioOther( this )'    \/>\r\n\t\t\t\t\t<label for='choice_1_16_1' id='label_1_16_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\r\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_19\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_2col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Did the doctor administer any memory or mental testing? (Check all that applied)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_19'><div class='gchoice gchoice_1_19_1'>\r\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.1' type='checkbox'  value='Asking you to name the current President or the date'  id='choice_1_19_1'   \/>\r\n\t\t\t\t\t\t\t\t<label for='choice_1_19_1' id='label_1_19_1' class='gform-field-label gform-field-label--type-inline'>Asking you to name the current President or the date<\/label>\r\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_19_2'>\r\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.2' type='checkbox'  value='Asking you to count backward from 100 by 7s (or a similar math test)'  id='choice_1_19_2'   \/>\r\n\t\t\t\t\t\t\t\t<label for='choice_1_19_2' id='label_1_19_2' class='gform-field-label gform-field-label--type-inline'>Asking you to count backward from 100 by 7s (or a similar math test)<\/label>\r\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_19_3'>\r\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.3' type='checkbox'  value='Asking you to repeat a list of 3 words back to them later in the interview'  id='choice_1_19_3'   \/>\r\n\t\t\t\t\t\t\t\t<label for='choice_1_19_3' id='label_1_19_3' class='gform-field-label gform-field-label--type-inline'>Asking you to repeat a list of 3 words back to them later in the interview<\/label>\r\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_19_4'>\r\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.4' type='checkbox'  value='Spelling a word backward (like W-O-R-L-D)'  id='choice_1_19_4'   \/>\r\n\t\t\t\t\t\t\t\t<label for='choice_1_19_4' id='label_1_19_4' class='gform-field-label gform-field-label--type-inline'>Spelling a word backward (like W-O-R-L-D)<\/label>\r\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_19_5'>\r\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.5' type='checkbox'  value='None of the above'  id='choice_1_19_5'   \/>\r\n\t\t\t\t\t\t\t\t<label for='choice_1_19_5' id='label_1_19_5' class='gform-field-label gform-field-label--type-inline'>None of the above<\/label>\r\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_3col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did the doctor ask about your daily struggles, anxiety, depression, or panic attacks?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_21'>\r\n\t\t\t<div class='gchoice gchoice_1_21_0'>\r\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Yes, extensively'  id='choice_1_21_0' onchange='gformToggleRadioOther( this )'    \/>\r\n\t\t\t\t\t<label for='choice_1_21_0' id='label_1_21_0' class='gform-field-label gform-field-label--type-inline'>Yes, extensively<\/label>\r\n\t\t\t<\/div>\r\n\t\t\t<div class='gchoice gchoice_1_21_1'>\r\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Yes, but very briefly'  id='choice_1_21_1' onchange='gformToggleRadioOther( this )'    \/>\r\n\t\t\t\t\t<label for='choice_1_21_1' id='label_1_21_1' class='gform-field-label gform-field-label--type-inline'>Yes, but very briefly<\/label>\r\n\t\t\t<\/div>\r\n\t\t\t<div class='gchoice gchoice_1_21_2'>\r\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='No, they skipped it entirely'  id='choice_1_21_2' onchange='gformToggleRadioOther( this )'    \/>\r\n\t\t\t\t\t<label for='choice_1_21_2' id='label_1_21_2' class='gform-field-label gform-field-label--type-inline'>No, they skipped it entirely<\/label>\r\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_3col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >How would you describe the doctor&#039;s attitude toward you?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_20'>\r\n\t\t\t<div class='gchoice gchoice_1_20_0'>\r\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Polite and professional'  id='choice_1_20_0' onchange='gformToggleRadioOther( this )'    \/>\r\n\t\t\t\t\t<label for='choice_1_20_0' id='label_1_20_0' class='gform-field-label gform-field-label--type-inline'>Polite and professional<\/label>\r\n\t\t\t<\/div>\r\n\t\t\t<div class='gchoice gchoice_1_20_1'>\r\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Rushed\/impatient'  id='choice_1_20_1' onchange='gformToggleRadioOther( this )'    \/>\r\n\t\t\t\t\t<label for='choice_1_20_1' id='label_1_20_1' class='gform-field-label gform-field-label--type-inline'>Rushed\/impatient<\/label>\r\n\t\t\t<\/div>\r\n\t\t\t<div class='gchoice gchoice_1_20_2'>\r\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Dismissive or rude'  id='choice_1_20_2' onchange='gformToggleRadioOther( this )'    \/>\r\n\t\t\t\t\t<label for='choice_1_20_2' id='label_1_20_2' class='gform-field-label gform-field-label--type-inline'>Dismissive or rude<\/label>\r\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did the doctor ask you how your medical conditions prevent you from working a regular job?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_22'>\r\n\t\t\t<div class='gchoice gchoice_1_22_0'>\r\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Yes'  id='choice_1_22_0' onchange='gformToggleRadioOther( this )'    \/>\r\n\t\t\t\t\t<label for='choice_1_22_0' id='label_1_22_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\r\n\t\t\t<\/div>\r\n\t\t\t<div class='gchoice gchoice_1_22_1'>\r\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='No'  id='choice_1_22_1' onchange='gformToggleRadioOther( this )'    \/>\r\n\t\t\t\t\t<label for='choice_1_22_1' id='label_1_22_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\r\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Did the doctor make any comments that felt strange, dismissive, or unfair?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_23'>\r\n\t\t\t<div class='gchoice gchoice_1_23_0'>\r\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Yes'  id='choice_1_23_0' onchange='gformToggleRadioOther( this )'    \/>\r\n\t\t\t\t\t<label for='choice_1_23_0' id='label_1_23_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\r\n\t\t\t<\/div>\r\n\t\t\t<div class='gchoice gchoice_1_23_1'>\r\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_1_23_1' onchange='gformToggleRadioOther( this )'    \/>\r\n\t\t\t\t\t<label for='choice_1_23_1' id='label_1_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\r\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_25\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above 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