{"id":13102,"date":"2024-08-30T12:32:00","date_gmt":"2024-08-30T12:32:00","guid":{"rendered":"https:\/\/rehablab.nl\/?page_id=13102"},"modified":"2024-08-30T13:39:36","modified_gmt":"2024-08-30T13:39:36","slug":"questionnaire-form","status":"publish","type":"page","link":"https:\/\/rehablab.nl\/nl\/questionnaire-form\/","title":{"rendered":"Questionary Form"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"13102\" class=\"elementor elementor-13102\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-137f8de elementor-section-boxed elementor-section-height-default elementor-section-height-default cmsmasters-block-default\" data-id=\"137f8de\" 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-top-column elementor-element elementor-element-494b43c\" data-id=\"494b43c\" 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-8727d83 cmsmasters-block-default cmsmasters-sticky-default elementor-widget elementor-widget-heading\" data-id=\"8727d83\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Thank you for registering!<span style=\"background-color: var(--cmsmasters-main-container-bg-color);color: var( --e-global-color-primary );font-family: var(--cmsmasters-h3-font-family);font-size: var(--cmsmasters-h3-font-size);font-style: var(--cmsmasters-h3-font-style);font-weight: var( --e-global-typography-primary-font-weight );letter-spacing: var(--cmsmasters-h3-letter-spacing);text-transform: var(--cmsmasters-h3-text-transform)\"><\/span><\/h1>\t\t\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<section class=\"elementor-section elementor-top-section elementor-element elementor-element-92a69df elementor-section-boxed elementor-section-height-default elementor-section-height-default cmsmasters-block-default\" data-id=\"92a69df\" 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-top-column elementor-element elementor-element-48c7d1e\" data-id=\"48c7d1e\" 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-7e1d47b cmsmasters-block-default cmsmasters-sticky-default elementor-widget elementor-widget-text-editor\" data-id=\"7e1d47b\" 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\t\t<p>To ensure you receive the best possible treatment, please fill out the form below.<\/p>\t\t\t\t\t\t\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<section class=\"elementor-section elementor-top-section elementor-element elementor-element-1b50e7d elementor-section-boxed elementor-section-height-default elementor-section-height-default cmsmasters-block-default\" data-id=\"1b50e7d\" 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-top-column elementor-element elementor-element-3079a36\" data-id=\"3079a36\" 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-9cecd75 cmsmasters-block-default cmsmasters-sticky-default elementor-widget elementor-widget-cmsmasters-forminator\" data-id=\"9cecd75\" data-element_type=\"widget\" data-settings=\"{&quot;form_list&quot;:&quot;13008&quot;}\" data-widget_type=\"cmsmasters-forminator.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-widget-cmsmasters-contact-form__wrapper elementor-widget-cmsmasters-contact-form cmsmasters-default-color cmsmasters-default-font\" id=\"cmsmasters-widget-form-9cecd75\">\n\t\t\t<div class=\"elementor-widget-cmsmasters-contact-form__inner\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-13008 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-13008\" data-uid=\"69e0e92b41680\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-13008\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-13008 forminator-design--default  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"13008\"\n\t\t\t\t data-color-option=\"default\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"69e0e92b41680\" action=\"\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_69e0e92b41680\" id=\"forminator-field-name-1_69e0e92b41680-label\" class=\"forminator-label\">Wat is je volledige naam? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_69e0e92b41680\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"number-1\" class=\"forminator-field-number forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-number-1_69e0e92b41680\" id=\"forminator-field-number-1_69e0e92b41680-label\" class=\"forminator-label\">Hoe oud ben je? <span class=\"forminator-required\">*<\/span><\/label><input name=\"number-1\" value=\"\" placeholder=\"\" id=\"forminator-field-number-1_69e0e92b41680\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"1\" data-decimals=\"0\" aria-required=\"true\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" data-hidden-behavior=\"zero\" type=\"number\" step=\"any\" min=\"1\" max=\"130\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_69e0e92b41680\" id=\"forminator-field-date-1-picker_69e0e92b41680-label\" class=\"forminator-label\">Wat is je geboortedatum? <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"\" id=\"forminator-field-date-1-picker_69e0e92b41680\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"mm-dd-yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-12\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-1-69e0e92b41680-label\"><span id=\"forminator-radiogroup-radio-1-69e0e92b41680-label\" class=\"forminator-label\">Wat is je geslacht? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-69e0e92b41680\" class=\"forminator-radio\" title=\"Male\"><input type=\"radio\" name=\"radio-1\" value=\"one\" id=\"forminator-field-radio-1-1-69e0e92b41680\" aria-labelledby=\"forminator-field-radio-1-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Male<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-69e0e92b41680\" class=\"forminator-radio\" title=\"Female\"><input type=\"radio\" name=\"radio-1\" value=\"two\" id=\"forminator-field-radio-1-2-69e0e92b41680\" aria-labelledby=\"forminator-field-radio-1-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Female<\/span><\/label><label id=\"forminator-field-radio-1-label-3\" for=\"forminator-field-radio-1-3-69e0e92b41680\" class=\"forminator-radio\" title=\"X\"><input type=\"radio\" name=\"radio-1\" value=\"X\" id=\"forminator-field-radio-1-3-69e0e92b41680\" aria-labelledby=\"forminator-field-radio-1-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">X<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_69e0e92b41680\" id=\"forminator-field-email-1_69e0e92b41680-label\" class=\"forminator-label\">What is your email address? <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_69e0e92b41680\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" autocomplete=\"email\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_69e0e92b41680\" id=\"forminator-field-phone-1_69e0e92b41680-label\" class=\"forminator-label\">Wat is uw telefoonnummer? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_69e0e92b41680\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"slider-1\" class=\"forminator-field-slider forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-slider-1_69e0e92b41680\" id=\"forminator-field-slider-1_69e0e92b41680-label\" class=\"forminator-label\">What is your fat percentage(if known)?<\/label><div class=\"forminator-slider forminator-slider-full forminator-slider-size-small\"><input type=\"text\" id=\"forminator-field-slider-1_69e0e92b41680\" class=\"forminator-hidden-input\" style=\"display:none;\"\/><div class=\"forminator-slide forminator-slide-handle-icon\" aria-required=\"false\" data-is-range=\"\" data-min=\"1\" data-max=\"100\" data-step=\"0.5\" data-value=\"1\"><\/div><div class=\"forminator-slider-limit\"><\/div><div class=\"forminator-slider-amount forminator-slider-amount-bottom\" data-value-template=\"{slider-value}%\"><span class=\"forminator-slider-value-min\"><\/span><input type=\"hidden\" value=\"\" data-hidden-behavior=\"zero\" id=\"forminator-field-slider-1-input_69e0e92b41680\" name=\"slider-1\" class=\"forminator-slider-hidden-min\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-19\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-19_69e0e92b41680\" id=\"forminator-field-text-19_69e0e92b41680-label\" class=\"forminator-label\">What is your weight(in kg)? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-19\" value=\"\" placeholder=\"\" id=\"forminator-field-text-19_69e0e92b41680\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-20\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-20_69e0e92b41680\" id=\"forminator-field-text-20_69e0e92b41680-label\" class=\"forminator-label\">Wat is je lengte (cm)? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-20\" value=\"\" placeholder=\"\" id=\"forminator-field-text-20_69e0e92b41680\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-18\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-18_69e0e92b41680\" id=\"forminator-field-text-18_69e0e92b41680-label\" class=\"forminator-label\">Wat is het belangrijkste probleem of de klacht waarvoor u hulp zoekt? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-18\" value=\"\" placeholder=\"\" id=\"forminator-field-text-18_69e0e92b41680\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-21\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-21_69e0e92b41680\" id=\"forminator-field-text-21_69e0e92b41680-label\" class=\"forminator-label\">Welke diagnose of pathologie heeft de arts\/specialist u gegeven? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-21\" value=\"\" placeholder=\"\" id=\"forminator-field-text-21_69e0e92b41680\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-22\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-22_69e0e92b41680\" id=\"forminator-field-text-22_69e0e92b41680-label\" class=\"forminator-label\">How long have you been experiencing these symptoms (months)? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-22\" value=\"\" placeholder=\"\" id=\"forminator-field-text-22_69e0e92b41680\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-2\" class=\"forminator-field-radio forminator-col forminator-col-12\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-2-69e0e92b41680-label\"><span id=\"forminator-radiogroup-radio-2-69e0e92b41680-label\" class=\"forminator-label\">Heeft u ooit eerder een fysiotherapiebehandeling gehad voor deze klachten?<\/span><label id=\"forminator-field-radio-2-label-1\" for=\"forminator-field-radio-2-1-69e0e92b41680\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-2\" value=\"one\" id=\"forminator-field-radio-2-1-69e0e92b41680\" aria-labelledby=\"forminator-field-radio-2-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-2-label-2\" for=\"forminator-field-radio-2-2-69e0e92b41680\" class=\"forminator-radio\" title=\"Nee\"><input type=\"radio\" name=\"radio-2\" value=\"two\" id=\"forminator-field-radio-2-2-69e0e92b41680\" aria-labelledby=\"forminator-field-radio-2-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Nee<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-23\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-23_69e0e92b41680\" id=\"forminator-field-text-23_69e0e92b41680-label\" class=\"forminator-label\">What is the maximum duration of time you can dedicate to training\/therapy (hours on weekly basis)? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-23\" value=\"\" placeholder=\"\" id=\"forminator-field-text-23_69e0e92b41680\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-24\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-24_69e0e92b41680\" id=\"forminator-field-text-24_69e0e92b41680-label\" class=\"forminator-label\">Welke sporten heeft u in het verleden beoefend en\/of beoefent u momenteel? Vermeld alle sporten die u minimaal vijf jaar of langer beoefent.<\/label><input type=\"text\" name=\"text-24\" value=\"\" placeholder=\"\" id=\"forminator-field-text-24_69e0e92b41680\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-25\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-25_69e0e92b41680\" id=\"forminator-field-text-25_69e0e92b41680-label\" class=\"forminator-label\">Kunt u specifieke activiteiten of momenten identificeren die uw symptomen verergeren of verbeteren?<\/label><input type=\"text\" name=\"text-25\" value=\"\" placeholder=\"\" id=\"forminator-field-text-25_69e0e92b41680\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-3\" class=\"forminator-field-radio forminator-col forminator-col-12\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-3-69e0e92b41680-label\"><span id=\"forminator-radiogroup-radio-3-69e0e92b41680-label\" class=\"forminator-label\">Hebben uw klachten invloed op uw dagelijks leven of werk?<\/span><label id=\"forminator-field-radio-3-label-1\" for=\"forminator-field-radio-3-1-69e0e92b41680\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-3\" value=\"one\" id=\"forminator-field-radio-3-1-69e0e92b41680\" aria-labelledby=\"forminator-field-radio-3-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-3-label-2\" for=\"forminator-field-radio-3-2-69e0e92b41680\" class=\"forminator-radio\" title=\"Nee\"><input type=\"radio\" name=\"radio-3\" value=\"two\" id=\"forminator-field-radio-3-2-69e0e92b41680\" aria-labelledby=\"forminator-field-radio-3-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Nee<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-4\" class=\"forminator-field-radio forminator-col forminator-col-12\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-4-69e0e92b41680-label\"><span id=\"forminator-radiogroup-radio-4-69e0e92b41680-label\" class=\"forminator-label\">Rookt u, en zo ja, hoeveel sigaretten rookt u doorgaans per dag?<\/span><label id=\"forminator-field-radio-4-label-1\" for=\"forminator-field-radio-4-1-69e0e92b41680\" class=\"forminator-radio\" title=\"I do not smoke\"><input type=\"radio\" name=\"radio-4\" value=\"one\" id=\"forminator-field-radio-4-1-69e0e92b41680\" aria-labelledby=\"forminator-field-radio-4-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">I do not smoke<\/span><\/label><label id=\"forminator-field-radio-4-label-2\" for=\"forminator-field-radio-4-2-69e0e92b41680\" class=\"forminator-radio\" title=\"1-5 cigarettes per day\"><input type=\"radio\" name=\"radio-4\" value=\"two\" id=\"forminator-field-radio-4-2-69e0e92b41680\" aria-labelledby=\"forminator-field-radio-4-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">1-5 cigarettes per day<\/span><\/label><label id=\"forminator-field-radio-4-label-3\" for=\"forminator-field-radio-4-3-69e0e92b41680\" class=\"forminator-radio\" title=\"5-10 cigarettes per day\"><input type=\"radio\" name=\"radio-4\" value=\"5-10-cigarettes-per-day\" id=\"forminator-field-radio-4-3-69e0e92b41680\" aria-labelledby=\"forminator-field-radio-4-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">5-10 cigarettes per day<\/span><\/label><label id=\"forminator-field-radio-4-label-4\" for=\"forminator-field-radio-4-4-69e0e92b41680\" class=\"forminator-radio\" title=\"10-15 cigarettes per day\"><input type=\"radio\" name=\"radio-4\" value=\"10-15-cigarettes-per-day\" id=\"forminator-field-radio-4-4-69e0e92b41680\" aria-labelledby=\"forminator-field-radio-4-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">10-15 cigarettes per day<\/span><\/label><label id=\"forminator-field-radio-4-label-5\" for=\"forminator-field-radio-4-5-69e0e92b41680\" class=\"forminator-radio\" title=\"15-20 cigarettes per day\"><input type=\"radio\" name=\"radio-4\" value=\"15-20-cigarettes-per-day\" id=\"forminator-field-radio-4-5-69e0e92b41680\" aria-labelledby=\"forminator-field-radio-4-label-5\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">15-20 cigarettes per day<\/span><\/label><label id=\"forminator-field-radio-4-label-6\" for=\"forminator-field-radio-4-6-69e0e92b41680\" class=\"forminator-radio\" title=\"More then 20 cigarettes per day\"><input type=\"radio\" name=\"radio-4\" value=\"More-then-20-cigarettes-per-day\" id=\"forminator-field-radio-4-6-69e0e92b41680\" aria-labelledby=\"forminator-field-radio-4-label-6\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">More then 20 cigarettes per day<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-26\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-26_69e0e92b41680\" id=\"forminator-field-text-26_69e0e92b41680-label\" class=\"forminator-label\">Hoe vaak drinkt u gemiddeld per week alcohol en hoeveel glazen drinkt u doorgaans tijdens een avondje uit?<\/label><input type=\"text\" name=\"text-26\" value=\"\" placeholder=\"\" id=\"forminator-field-text-26_69e0e92b41680\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_69e0e92b41680\" id=\"forminator-field-text-1_69e0e92b41680-label\" class=\"forminator-label\">Zijn er nog andere medische aandoeningen waarvan we op de hoogte moeten zijn? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_69e0e92b41680\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_69e0e92b41680\" id=\"forminator-field-text-2_69e0e92b41680-label\" class=\"forminator-label\">Gebruikt u momenteel medicijnen die relevant zijn voor uw behandeling? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_69e0e92b41680\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_69e0e92b41680\" id=\"forminator-field-text-3_69e0e92b41680-label\" class=\"forminator-label\">Wat zijn uw specifieke doelstellingen voor de fysiotherapeutische behandeling?<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_69e0e92b41680\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-27\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-27_69e0e92b41680\" id=\"forminator-field-text-27_69e0e92b41680-label\" class=\"forminator-label\">Hoe be\u00efnvloeden uw symptomen uw algehele kwaliteit van leven? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-27\" value=\"\" placeholder=\"\" id=\"forminator-field-text-27_69e0e92b41680\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_69e0e92b41680\" id=\"forminator-field-text-4_69e0e92b41680-label\" class=\"forminator-label\">Waar voelt u de meeste pijn of ongemak? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_69e0e92b41680\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_69e0e92b41680\" id=\"forminator-field-text-5_69e0e92b41680-label\" class=\"forminator-label\">Kunt u specifieke bewegingen of activiteiten identificeren die uw symptomen veroorzaken?<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5_69e0e92b41680\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_69e0e92b41680\" id=\"forminator-field-text-6_69e0e92b41680-label\" class=\"forminator-label\">Wat voor soort pijn ervaart u? (bijvoorbeeld scherp, brandend, dof) <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"\" id=\"forminator-field-text-6_69e0e92b41680\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-7\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-7_69e0e92b41680\" id=\"forminator-field-text-7_69e0e92b41680-label\" class=\"forminator-label\">Hoe vaak ervaart u pijn? Is het constant of treedt het op tijdens bepaalde bewegingen of activiteiten? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-7\" value=\"\" placeholder=\"\" id=\"forminator-field-text-7_69e0e92b41680\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-8\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-8_69e0e92b41680\" id=\"forminator-field-text-8_69e0e92b41680-label\" class=\"forminator-label\">Beperken uw klachten uw mobiliteit of dagelijks functioneren? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-8\" value=\"\" placeholder=\"\" id=\"forminator-field-text-8_69e0e92b41680\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-9\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-9_69e0e92b41680\" id=\"forminator-field-text-9_69e0e92b41680-label\" class=\"forminator-label\">Heeft u behandelingen of oefeningen voor uw symptomen geprobeerd? Zo ja, wat waren de resultaten?<\/label><input type=\"text\" name=\"text-9\" value=\"\" placeholder=\"\" id=\"forminator-field-text-9_69e0e92b41680\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-10\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-10_69e0e92b41680\" id=\"forminator-field-text-10_69e0e92b41680-label\" class=\"forminator-label\">Zijn er activiteiten die u graag zou willen doen, maar momenteel niet kunt vanwege uw klachten? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-10\" value=\"\" placeholder=\"\" id=\"forminator-field-text-10_69e0e92b41680\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-5\" class=\"forminator-field-radio forminator-col forminator-col-12\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-5-69e0e92b41680-label\"><span id=\"forminator-radiogroup-radio-5-69e0e92b41680-label\" class=\"forminator-label\">Bent u zich bewust van de manier waarop uw houding uw symptomen kan be\u00efnvloeden?<\/span><label id=\"forminator-field-radio-5-label-1\" for=\"forminator-field-radio-5-1-69e0e92b41680\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-5\" value=\"one\" id=\"forminator-field-radio-5-1-69e0e92b41680\" aria-labelledby=\"forminator-field-radio-5-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-5-label-2\" for=\"forminator-field-radio-5-2-69e0e92b41680\" class=\"forminator-radio\" title=\"Nee\"><input type=\"radio\" name=\"radio-5\" value=\"two\" id=\"forminator-field-radio-5-2-69e0e92b41680\" aria-labelledby=\"forminator-field-radio-5-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Nee<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-12\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-12_69e0e92b41680\" id=\"forminator-field-text-12_69e0e92b41680-label\" class=\"forminator-label\">Welke specifieke doelen heeft u voor het verbeteren van uw mobiliteit, kracht of het verminderen van pijn? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-12\" value=\"\" placeholder=\"\" id=\"forminator-field-text-12_69e0e92b41680\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-13\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-13_69e0e92b41680\" id=\"forminator-field-text-13_69e0e92b41680-label\" class=\"forminator-label\">Welke bewegingen\/acties veroorzaken of verergeren de pijn? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-13\" value=\"\" placeholder=\"\" id=\"forminator-field-text-13_69e0e92b41680\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-6\" class=\"forminator-field-radio forminator-col forminator-col-12\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-6-69e0e92b41680-label\"><span id=\"forminator-radiogroup-radio-6-69e0e92b41680-label\" class=\"forminator-label\">Heeft u een operatie ondergaan? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-6-label-1\" for=\"forminator-field-radio-6-1-69e0e92b41680\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-6\" value=\"one\" id=\"forminator-field-radio-6-1-69e0e92b41680\" aria-labelledby=\"forminator-field-radio-6-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-6-label-2\" for=\"forminator-field-radio-6-2-69e0e92b41680\" class=\"forminator-radio\" title=\"Nee\"><input type=\"radio\" name=\"radio-6\" value=\"two\" id=\"forminator-field-radio-6-2-69e0e92b41680\" aria-labelledby=\"forminator-field-radio-6-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Nee<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-14\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-14_69e0e92b41680\" id=\"forminator-field-text-14_69e0e92b41680-label\" class=\"forminator-label\">Welk type operatie heeft u ondergaan? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-14\" value=\"\" placeholder=\"\" id=\"forminator-field-text-14_69e0e92b41680\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-28\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-28_69e0e92b41680\" id=\"forminator-field-text-28_69e0e92b41680-label\" class=\"forminator-label\">Wat is de voorgeschreven behandeling door de orthopeed? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-28\" value=\"\" placeholder=\"\" id=\"forminator-field-text-28_69e0e92b41680\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-7\" class=\"forminator-field-radio forminator-col forminator-col-12\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-7-69e0e92b41680-label\"><span id=\"forminator-radiogroup-radio-7-69e0e92b41680-label\" class=\"forminator-label\">Mag je gewicht dragen? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-7-label-1\" for=\"forminator-field-radio-7-1-69e0e92b41680\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-7\" value=\"one\" id=\"forminator-field-radio-7-1-69e0e92b41680\" aria-labelledby=\"forminator-field-radio-7-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-7-label-2\" for=\"forminator-field-radio-7-2-69e0e92b41680\" class=\"forminator-radio\" title=\"Nee\"><input type=\"radio\" name=\"radio-7\" value=\"two\" id=\"forminator-field-radio-7-2-69e0e92b41680\" aria-labelledby=\"forminator-field-radio-7-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Nee<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-15\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-15_69e0e92b41680\" id=\"forminator-field-text-15_69e0e92b41680-label\" class=\"forminator-label\">Welke bewegingen\/handelingen verlichten of verlichten de pijn? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-15\" value=\"\" placeholder=\"\" id=\"forminator-field-text-15_69e0e92b41680\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-16\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-16_69e0e92b41680\" id=\"forminator-field-text-16_69e0e92b41680-label\" class=\"forminator-label\">Heeft u thuis trainingsapparatuur\/faciliteiten (voor uw persoonlijke trainingsplan)? Zo ja, geef dan aan welke apparatuur u tot uw beschikking heeft. <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-16\" value=\"\" placeholder=\"\" id=\"forminator-field-text-16_69e0e92b41680\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-17\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-17_69e0e92b41680\" id=\"forminator-field-text-17_69e0e92b41680-label\" class=\"forminator-label\">Wanneer is uw volgende afspraak met de arts? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-17\" value=\"\" placeholder=\"\" id=\"forminator-field-text-17_69e0e92b41680\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-29\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-29_69e0e92b41680\" id=\"forminator-field-text-29_69e0e92b41680-label\" class=\"forminator-label\">Heeft u nog andere zorgen of vragen over uw klachten die u graag wilt bespreken? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-29\" value=\"\" placeholder=\"\" id=\"forminator-field-text-29_69e0e92b41680\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Indienen<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"1fe1cef5ed\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/nl\/wp-json\/wp\/v2\/pages\/13102\" \/><input type=\"hidden\" name=\"form_id\" value=\"13008\"><input type=\"hidden\" name=\"page_id\" value=\"13102\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/rehablab.nl\/nl\/questionnaire-form\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><input type=\"hidden\" name=\"trp-form-language\" value=\"nl\"\/><\/form><\/div>\n\t\t<\/div>\t\t\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<\/div>","protected":false},"excerpt":{"rendered":"<p>Thank you for registering! To ensure you receive the best possible treatment, please fill out the form below.<\/p>","protected":false},"author":16,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"inline_featured_image":false,"footnotes":""},"class_list":["post-13102","page","type-page","status-publish","hentry"],"acf":[],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/rehablab.nl\/nl\/wp-json\/wp\/v2\/pages\/13102","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/rehablab.nl\/nl\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/rehablab.nl\/nl\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/rehablab.nl\/nl\/wp-json\/wp\/v2\/users\/16"}],"replies":[{"embeddable":true,"href":"https:\/\/rehablab.nl\/nl\/wp-json\/wp\/v2\/comments?post=13102"}],"version-history":[{"count":28,"href":"https:\/\/rehablab.nl\/nl\/wp-json\/wp\/v2\/pages\/13102\/revisions"}],"predecessor-version":[{"id":13134,"href":"https:\/\/rehablab.nl\/nl\/wp-json\/wp\/v2\/pages\/13102\/revisions\/13134"}],"wp:attachment":[{"href":"https:\/\/rehablab.nl\/nl\/wp-json\/wp\/v2\/media?parent=13102"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}