{"id":1166,"date":"2026-11-01T14:44:20","date_gmt":"2026-11-01T14:44:20","guid":{"rendered":"https:\/\/surgeryweb-scot.org.uk\/55003\/?page_id=1166"},"modified":"2026-11-01T14:44:29","modified_gmt":"2026-11-01T14:44:29","slug":"asthma-review-form","status":"publish","type":"page","link":"https:\/\/surgeryweb-scot.org.uk\/55003\/annual-birthday-reviews\/asthma-review-form\/","title":{"rendered":"Asthma Review Form"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_23' style='display:none'><div id='gf_23' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_23' id='gform_23'  action='\/55003\/wp-json\/wp\/v2\/pages\/1166#gf_23' data-formid='23' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_23' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fixed'><div id=\"field_23_37\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"><label id='gfield_label_23_37' class='gfield_label gform-field-label' for='input_23_37'><span class='gform-field-label__text'>Comments<\/span><\/label><div class='ginput_container'><input name='input_37' id='input_23_37' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_23_37'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_23_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"1dc62a55\" data-field-span=\"12\"><label id='gfield_label_23_1' class='gfield_label gform-field-label' for='input_23_1'><span class='gform-field-label__text'>Full Name<\/span><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_1' id='input_23_1' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_3\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"ced91279\" data-field-span=\"12\"><label id='gfield_label_23_3' class='gfield_label gform-field-label' for='input_23_3'><span class='gform-field-label__text'>Date of Birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='dd\/mm\/yyyy'\n\t\t\t\t\tid='input_23_3'\n\t\t\t\t\tclass='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_3'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_23_3' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_23_3' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_23_3' aria-label='Date of Birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_23_4\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"5f7abbee\" data-field-span=\"12\"><label id='gfield_label_23_4' class='gfield_label gform-field-label' for='input_23_4'><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_4' id='input_23_4' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_23_5\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"58b7408b\" data-field-span=\"12\"><label id='gfield_label_23_5' class='gfield_label gform-field-label' for='input_23_5'><span class='gform-field-label__text'>Phone Number<\/span><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_5' id='input_23_5' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_6\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"7a952958\" data-field-span=\"12\"><h3 class=\"gsection_title\">Please complete the following questions to allow your health care professional to assess your asthma.<\/h3><\/div><fieldset id=\"field_23_7\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"c798f03a\" data-field-span=\"12\"><legend id='gfield_label_23_7' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>How often does your asthma cause symptoms during the day?<\/span><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_23_7'>\n\t\t\t<div class='gchoice gchoice_23_7_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Never'  id='choice_23_7_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_23_7_0 gfield_label_23_7\"   \/>\n\t\t\t\t\t<label for='choice_23_7_0' id='label_23_7_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_7_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='1 to 2 times per month'  id='choice_23_7_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_7_1' id='label_23_7_1' class='gform-field-label gform-field-label--type-inline'>1 to 2 times per month<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_7_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='1 to 2 times per week'  id='choice_23_7_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_7_2' id='label_23_7_2' class='gform-field-label gform-field-label--type-inline'>1 to 2 times per week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_7_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Most days'  id='choice_23_7_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_7_3' id='label_23_7_3' class='gform-field-label gform-field-label--type-inline'>Most days<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_8\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"5c2cce4c\" data-field-span=\"12\"><legend id='gfield_label_23_8' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>How often does your asthma cause symptoms at night?<\/span><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_23_8'>\n\t\t\t<div class='gchoice gchoice_23_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Never'  id='choice_23_8_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_23_8_0 gfield_label_23_8\"   \/>\n\t\t\t\t\t<label for='choice_23_8_0' id='label_23_8_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='1 to 2 times per month'  id='choice_23_8_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_8_1' id='label_23_8_1' class='gform-field-label gform-field-label--type-inline'>1 to 2 times per month<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_8_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='1 to 2 times per week'  id='choice_23_8_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_8_2' id='label_23_8_2' class='gform-field-label gform-field-label--type-inline'>1 to 2 times per week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_8_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Most days'  id='choice_23_8_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_8_3' id='label_23_8_3' class='gform-field-label gform-field-label--type-inline'>Most days<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"8844c3be\" data-field-span=\"12\"><legend id='gfield_label_23_9' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>How often does your asthma limit your activities?<\/span><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_23_9'>\n\t\t\t<div class='gchoice gchoice_23_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Never'  id='choice_23_9_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_23_9_0 gfield_label_23_9\"   \/>\n\t\t\t\t\t<label for='choice_23_9_0' id='label_23_9_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='1 to 2 times per month'  id='choice_23_9_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_9_1' id='label_23_9_1' class='gform-field-label gform-field-label--type-inline'>1 to 2 times per month<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_9_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='1 to 2 times per week'  id='choice_23_9_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_9_2' id='label_23_9_2' class='gform-field-label gform-field-label--type-inline'>1 to 2 times per week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_9_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Most days'  id='choice_23_9_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_9_3' id='label_23_9_3' class='gform-field-label gform-field-label--type-inline'>Most days<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_10\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"8c8698cc\" data-field-span=\"12\"><label id='gfield_label_23_10' class='gfield_label gform-field-label' for='input_23_10'><span class='gform-field-label__text'>How many asthma exacerbations (attacked) have you had in the past year?<\/span><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_10' id='input_23_10' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"0a59ecab\" data-field-span=\"12\"><label id='gfield_label_23_11' class='gfield_label gform-field-label' for='input_23_11'><span class='gform-field-label__text'>How many times have you attended Accident and Emergency Department since your last asthma review?<\/span><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_11' id='input_23_11' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_12\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"4f32b7e6\" data-field-span=\"12\"><h3 class=\"gsection_title\">Inhaler Technique<\/h3><\/div><fieldset id=\"field_23_13\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"595f1638\" data-field-span=\"12\"><legend id='gfield_label_23_13' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Please select the types of inhalers that you use<\/span><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_23_13'><div class='gchoice gchoice_23_13_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.1' type='checkbox'  value='Metered Dose Inhaler'  id='choice_23_13_1'    aria-labelledby=\"label_23_13_1 gfield_label_23_13\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_23_13_1' id='label_23_13_1' class='gform-field-label gform-field-label--type-inline'>Metered Dose Inhaler<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_13_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.2' type='checkbox'  value='Autohaler'  id='choice_23_13_2'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_13_2' id='label_23_13_2' class='gform-field-label gform-field-label--type-inline'>Autohaler<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_13_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.3' type='checkbox'  value='Accuhaler'  id='choice_23_13_3'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_13_3' id='label_23_13_3' class='gform-field-label gform-field-label--type-inline'>Accuhaler<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_13_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.4' type='checkbox'  value='EasiBreathe Inhaler'  id='choice_23_13_4'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_13_4' id='label_23_13_4' class='gform-field-label gform-field-label--type-inline'>EasiBreathe Inhaler<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_13_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.5' type='checkbox'  value='Easyhaler'  id='choice_23_13_5'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_13_5' id='label_23_13_5' class='gform-field-label gform-field-label--type-inline'>Easyhaler<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_13_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.6' type='checkbox'  value='Turbohaler'  id='choice_23_13_6'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_13_6' id='label_23_13_6' class='gform-field-label gform-field-label--type-inline'>Turbohaler<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_13_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.7' type='checkbox'  value='Small Volume Spacer'  id='choice_23_13_7'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_13_7' id='label_23_13_7' class='gform-field-label gform-field-label--type-inline'>Small Volume Spacer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_13_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.8' type='checkbox'  value='Large Volume Spacer'  id='choice_23_13_8'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_13_8' id='label_23_13_8' class='gform-field-label gform-field-label--type-inline'>Large Volume Spacer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_13_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.9' type='checkbox'  value='My inhaler is not listed here'  id='choice_23_13_9'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_13_9' id='label_23_13_9' class='gform-field-label gform-field-label--type-inline'>My inhaler is not listed here<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"49c92320\" data-field-span=\"12\"><label id='gfield_label_23_14' class='gfield_label gform-field-label' for='input_23_14'><span class='gform-field-label__text'>Please specify your inhaler<\/span><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_14' id='input_23_14' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_15\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"0b46f422\" data-field-span=\"12\"><h3 class=\"gsection_title\">Lifestyle - Alcohol<\/h3><\/div><fieldset id=\"field_23_16\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"a5111dd4\" data-field-span=\"12\"><legend id='gfield_label_23_16' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>How often do you have a drink containing alcohol?<\/span><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_23_16'>\n\t\t\t<div class='gchoice gchoice_23_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Never'  id='choice_23_16_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_23_16_0 gfield_label_23_16\"   \/>\n\t\t\t\t\t<label for='choice_23_16_0' id='label_23_16_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Monthly or less'  id='choice_23_16_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_16_1' id='label_23_16_1' class='gform-field-label gform-field-label--type-inline'>Monthly or less<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_16_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='2-4 times a month'  id='choice_23_16_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_16_2' id='label_23_16_2' class='gform-field-label gform-field-label--type-inline'>2-4 times a month<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_16_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='2-3 times a week'  id='choice_23_16_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_16_3' id='label_23_16_3' class='gform-field-label gform-field-label--type-inline'>2-3 times a week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_16_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='4 times or more a week'  id='choice_23_16_4' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_16_4' id='label_23_16_4' class='gform-field-label gform-field-label--type-inline'>4 times or more a week<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_17\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"0f14c3cd\" data-field-span=\"12\"><legend id='gfield_label_23_17' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>How many units of alcohol do you drink on a typical day drinking?<\/span><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_23_17'>\n\t\t\t<div class='gchoice gchoice_23_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='1 - 2'  id='choice_23_17_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_23_17_0 gfield_label_23_17\"   \/>\n\t\t\t\t\t<label for='choice_23_17_0' id='label_23_17_0' class='gform-field-label gform-field-label--type-inline'>1 - 2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='3 - 4'  id='choice_23_17_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_17_1' id='label_23_17_1' class='gform-field-label gform-field-label--type-inline'>3 - 4<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_17_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='5 - 6'  id='choice_23_17_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_17_2' id='label_23_17_2' class='gform-field-label gform-field-label--type-inline'>5 - 6<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_17_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='7 - 9'  id='choice_23_17_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_17_3' id='label_23_17_3' class='gform-field-label gform-field-label--type-inline'>7 - 9<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_17_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='10+'  id='choice_23_17_4' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_17_4' id='label_23_17_4' class='gform-field-label gform-field-label--type-inline'>10+<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_18\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"3bb70d2b\" data-field-span=\"12\"><legend id='gfield_label_23_18' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?<\/span><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_23_18'>\n\t\t\t<div class='gchoice gchoice_23_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Never'  id='choice_23_18_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_23_18_0 gfield_label_23_18\"   \/>\n\t\t\t\t\t<label for='choice_23_18_0' id='label_23_18_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Less than monthly'  id='choice_23_18_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_18_1' id='label_23_18_1' class='gform-field-label gform-field-label--type-inline'>Less than monthly<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_18_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Monthly'  id='choice_23_18_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_18_2' id='label_23_18_2' class='gform-field-label gform-field-label--type-inline'>Monthly<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_18_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Weekly'  id='choice_23_18_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_18_3' id='label_23_18_3' class='gform-field-label gform-field-label--type-inline'>Weekly<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_18_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Daily or almost daily'  id='choice_23_18_4' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_18_4' id='label_23_18_4' class='gform-field-label gform-field-label--type-inline'>Daily or almost daily<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_19\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"78829b9a\" data-field-span=\"12\"><h3 class=\"gsection_title\">Lifestyle - Smoking<\/h3><\/div><fieldset id=\"field_23_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"16323b5a\" data-field-span=\"12\"><legend id='gfield_label_23_20' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you smoke?<\/span><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_23_20'>\n\t\t\t<div class='gchoice gchoice_23_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Never smoked'  id='choice_23_20_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_23_20_0 gfield_label_23_20\"   \/>\n\t\t\t\t\t<label for='choice_23_20_0' id='label_23_20_0' class='gform-field-label gform-field-label--type-inline'>Never smoked<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Ex-smoker'  id='choice_23_20_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_20_1' id='label_23_20_1' class='gform-field-label gform-field-label--type-inline'>Ex-smoker<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_20_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Trivial smoker (less than 1 cigarette per day)'  id='choice_23_20_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_20_2' id='label_23_20_2' class='gform-field-label gform-field-label--type-inline'>Trivial smoker (less than 1 cigarette per day)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_20_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Light Smoker (1-9 cigarettes per day)'  id='choice_23_20_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_20_3' id='label_23_20_3' class='gform-field-label gform-field-label--type-inline'>Light Smoker (1-9 cigarettes per day)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_20_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Moderate smoker (10-19 cigarettes per day)'  id='choice_23_20_4' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_20_4' id='label_23_20_4' class='gform-field-label gform-field-label--type-inline'>Moderate smoker (10-19 cigarettes per day)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_20_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Heavy smoker (20-39 cigarettes per day)'  id='choice_23_20_5' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_20_5' id='label_23_20_5' class='gform-field-label gform-field-label--type-inline'>Heavy smoker (20-39 cigarettes per day)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_20_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Very heavy smoker (40 or more cigarettes per day)'  id='choice_23_20_6' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_20_6' id='label_23_20_6' class='gform-field-label gform-field-label--type-inline'>Very heavy smoker (40 or more cigarettes per day)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"911b6494\" data-field-span=\"12\"><legend id='gfield_label_23_21' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you use an e-cigarette?<\/span><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_23_21'>\n\t\t\t<div class='gchoice gchoice_23_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='No'  id='choice_23_21_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_23_21_0 gfield_label_23_21\"   \/>\n\t\t\t\t\t<label for='choice_23_21_0' id='label_23_21_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Ex-user'  id='choice_23_21_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_21_1' id='label_23_21_1' class='gform-field-label gform-field-label--type-inline'>Ex-user<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_21_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Yes'  id='choice_23_21_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_21_2' id='label_23_21_2' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"b47d91db\" data-field-span=\"12\"><legend id='gfield_label_23_22' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Would you like help to quit smoking?<\/span><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_23_22'>\n\t\t\t<div class='gchoice gchoice_23_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Yes'  id='choice_23_22_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_23_22_0 gfield_label_23_22\"   \/>\n\t\t\t\t\t<label for='choice_23_22_0' id='label_23_22_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='No'  id='choice_23_22_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_22_1' id='label_23_22_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_23\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"2fe80254\" data-field-span=\"12\"><p>For further information, please see: <a href=\"https:\/\/www.nhs.uk\/better-health\/quit-smoking\/\" target=\"_blank\">nhs.uk\/quit-smoking<\/a><\/p><\/div><div id=\"field_23_24\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"aeda1b85\" data-field-span=\"12\"><h3 class=\"gsection_title\">Asthma Control Test Score<\/h3><\/div><fieldset id=\"field_23_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"1f422c84\" data-field-span=\"12\"><legend id='gfield_label_23_25' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home?<\/span><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_23_25'>\n\t\t\t<div class='gchoice gchoice_23_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='1'  id='choice_23_25_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_23_25_0 gfield_label_23_25\"   \/>\n\t\t\t\t\t<label for='choice_23_25_0' id='label_23_25_0' class='gform-field-label gform-field-label--type-inline'>All of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='2'  id='choice_23_25_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_25_1' id='label_23_25_1' class='gform-field-label gform-field-label--type-inline'>Most of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_25_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='3'  id='choice_23_25_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_25_2' id='label_23_25_2' class='gform-field-label gform-field-label--type-inline'>Some of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_25_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='4'  id='choice_23_25_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_25_3' id='label_23_25_3' class='gform-field-label gform-field-label--type-inline'>A little of the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_25_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='5'  id='choice_23_25_4' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_25_4' id='label_23_25_4' class='gform-field-label gform-field-label--type-inline'>None of the time<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_28\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"b5f0ad58\" data-field-span=\"12\"><legend id='gfield_label_23_28' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>How often have you had shortness of breath?<\/span><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_23_28'>\n\t\t\t<div class='gchoice gchoice_23_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='1'  id='choice_23_28_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_23_28_0 gfield_label_23_28\"   \/>\n\t\t\t\t\t<label for='choice_23_28_0' id='label_23_28_0' class='gform-field-label gform-field-label--type-inline'>More than once a day<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='2'  id='choice_23_28_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_28_1' id='label_23_28_1' class='gform-field-label gform-field-label--type-inline'>Once a day<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_28_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='3'  id='choice_23_28_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_28_2' id='label_23_28_2' class='gform-field-label gform-field-label--type-inline'>3-6 times a week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_28_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='4'  id='choice_23_28_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_28_3' id='label_23_28_3' class='gform-field-label gform-field-label--type-inline'>1-2 times a week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_28_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='5'  id='choice_23_28_4' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_28_4' id='label_23_28_4' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_29\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"a702ec11\" data-field-span=\"12\"><legend id='gfield_label_23_29' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>How often did your asthma symptoms (wheezing, coughing, chest tightness, shortness of breath) wake you up at night or earlier than usual in the morning?<\/span><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_23_29'>\n\t\t\t<div class='gchoice gchoice_23_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='1'  id='choice_23_29_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_23_29_0 gfield_label_23_29\"   \/>\n\t\t\t\t\t<label for='choice_23_29_0' id='label_23_29_0' class='gform-field-label gform-field-label--type-inline'>4 or more times a week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='2'  id='choice_23_29_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_29_1' id='label_23_29_1' class='gform-field-label gform-field-label--type-inline'>2-3 nights a week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_29_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='3'  id='choice_23_29_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_29_2' id='label_23_29_2' class='gform-field-label gform-field-label--type-inline'>Once a week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_29_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='4'  id='choice_23_29_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_29_3' id='label_23_29_3' class='gform-field-label gform-field-label--type-inline'>Once or twice<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_29_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='5'  id='choice_23_29_4' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_29_4' id='label_23_29_4' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"9b374039\" data-field-span=\"12\"><legend id='gfield_label_23_30' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>How often have you used your reliever inhaler (usually blue)?<\/span><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_23_30'>\n\t\t\t<div class='gchoice gchoice_23_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='1'  id='choice_23_30_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_23_30_0 gfield_label_23_30\"   \/>\n\t\t\t\t\t<label for='choice_23_30_0' id='label_23_30_0' class='gform-field-label gform-field-label--type-inline'>3 or more times a day<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='2'  id='choice_23_30_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_30_1' id='label_23_30_1' class='gform-field-label gform-field-label--type-inline'>1-2 times a day<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_30_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='3'  id='choice_23_30_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_30_2' id='label_23_30_2' class='gform-field-label gform-field-label--type-inline'>2-3 times a week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_30_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='4'  id='choice_23_30_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_30_3' id='label_23_30_3' class='gform-field-label gform-field-label--type-inline'>Once a week or less<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_30_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='5'  id='choice_23_30_4' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_30_4' id='label_23_30_4' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_31\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"715492db\" data-field-span=\"12\"><legend id='gfield_label_23_31' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>How would you rate your asthma control?<\/span><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_23_31'>\n\t\t\t<div class='gchoice gchoice_23_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='1'  id='choice_23_31_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_23_31_0 gfield_label_23_31\"   \/>\n\t\t\t\t\t<label for='choice_23_31_0' id='label_23_31_0' class='gform-field-label gform-field-label--type-inline'>Not controlled<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='2'  id='choice_23_31_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_31_1' id='label_23_31_1' class='gform-field-label gform-field-label--type-inline'>Poorly controlled<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_31_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='3'  id='choice_23_31_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_31_2' id='label_23_31_2' class='gform-field-label gform-field-label--type-inline'>Somewhat controlled<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_31_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='4'  id='choice_23_31_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_31_3' id='label_23_31_3' class='gform-field-label gform-field-label--type-inline'>Well controlled<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_31_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='5'  id='choice_23_31_4' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_23_31_4' id='label_23_31_4' class='gform-field-label gform-field-label--type-inline'>Completely controlled<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_27\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"41b5d1c0\" data-field-span=\"12\"><label id='gfield_label_23_27' class='gfield_label gform-field-label' for='input_23_27'><span class='gform-field-label__text'>Your Calculated Asthma score<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_27' id='input_23_27' type='text' step='any'   value='' class='large gform-text-input-reset'  readonly=\"readonly\"   aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_23_32\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"8fc60a23\" data-field-span=\"12\"><div style=\"background: red; padding: 30px; color: #fff;\">\n<p>Your score is less than 20.<\/p>\n<p>Your asthma may not have been controlled during the past 4 weeks.<\/p>\n<p>Your doctor or nurse can recommend an asthma action plan to help improve your asthma control.<\/p>\n<\/div><\/div><div id=\"field_23_33\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"0d0ec46f\" data-field-span=\"12\"><div style=\"background: orange; padding: 30px; color: #000;\">\n<p>Your score is between 20 and 24.<\/p>\n<p>Your asthma appears to have been reasonably well controlled during the past 4 weeks.<\/p>\n<p>However, if you are experiencing symptoms your doctor or nurse may be able to help you.<\/p>\n<\/div><\/div><div id=\"field_23_34\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"af3118e3\" data-field-span=\"12\"><div style=\"background: green; padding: 30px; color: #fff;\">\n<p>Your score is 25, well done!<\/p>\n<p>Your asthma appears to have been under control over the last 4 weeks.<\/p>\n<p>However, if you are experiencing any problems with your asthma, you should see your doctor or nurse.<\/p>\n<\/div><\/div><div id=\"field_23_35\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"8c61c484\" data-field-span=\"12\"><h3 class=\"gsection_title\">Further Questions<\/h3><\/div><div id=\"field_23_36\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"d994d6e6\" data-field-span=\"12\"><label id='gfield_label_23_36' class='gfield_label gform-field-label' for='input_23_36'><span class='gform-field-label__text'>I have the following information, questions or concerns that I would like to raise with my Asthma Nurse or Doctor<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_36' id='input_23_36' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_23' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Submit<\/button> <input type='hidden' name='gform_ajax' 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