{"id":100,"date":"2023-07-05T06:58:30","date_gmt":"2023-07-05T06:58:30","guid":{"rendered":"https:\/\/appointment.srujanahospital.com\/?page_id=100"},"modified":"2023-07-12T14:03:23","modified_gmt":"2023-07-12T14:03:23","slug":"iciq-ui-short-form","status":"publish","type":"page","link":"https:\/\/appointment.srujanahospital.com\/index.php\/iciq-ui-short-form\/","title":{"rendered":"ICIQ-UI Short Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"100\" class=\"elementor elementor-100\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-19b1c96 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"19b1c96\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-68c0700\" data-id=\"68c0700\" 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-8c559be elementor-widget elementor-widget-heading\" data-id=\"8c559be\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.23.0 - 05-08-2024 *\/\n.elementor-heading-title{padding:0;margin:0;line-height:1}.elementor-widget-heading .elementor-heading-title[class*=elementor-size-]>a{color:inherit;font-size:inherit;line-height:inherit}.elementor-widget-heading .elementor-heading-title.elementor-size-small{font-size:15px}.elementor-widget-heading .elementor-heading-title.elementor-size-medium{font-size:19px}.elementor-widget-heading .elementor-heading-title.elementor-size-large{font-size:29px}.elementor-widget-heading .elementor-heading-title.elementor-size-xl{font-size:39px}.elementor-widget-heading .elementor-heading-title.elementor-size-xxl{font-size:59px}<\/style><h2 class=\"elementor-heading-title elementor-size-default\">ICIQ-UI Short Form<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-cfe7332 elementor-widget elementor-widget-wpforms\" data-id=\"cfe7332\" data-element_type=\"widget\" data-widget_type=\"wpforms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style id=\"wpforms-css-vars-root\">\n\t\t\t\t:root {\n\t\t\t\t\t--wpforms-field-border-radius: 3px;\n--wpforms-field-background-color: #ffffff;\n--wpforms-field-border-color: rgba( 0, 0, 0, 0.25 );\n--wpforms-field-text-color: rgba( 0, 0, 0, 0.7 );\n--wpforms-label-color: rgba( 0, 0, 0, 0.85 );\n--wpforms-label-sublabel-color: rgba( 0, 0, 0, 0.55 );\n--wpforms-label-error-color: #d63637;\n--wpforms-button-border-radius: 3px;\n--wpforms-button-background-color: #066aab;\n--wpforms-button-text-color: #ffffff;\n--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n\n\t\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-84\"><form id=\"wpforms-form-84\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"84\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/100\" data-token=\"c5bd839dff7f34266b88021ae3bcef96\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-84-field_2-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"2\"><div id=\"wpforms-84-field_2\" aria-errormessage=\"wpforms-84-field_2-error\">Many people leak urine some of the time. We are trying to find out how many people leak urine,\r\nand how much this bothers them. We would be grateful if you could answer the following\r\nquestions, thinking about how you have been, on average, over the PAST FOUR WEEKS.\r\n<\/div><\/div><div id=\"wpforms-84-field_10-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"10\"><fieldset><legend class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-84-field_10\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][10][first]\" aria-errormessage=\"wpforms-84-field_10-error\" required><label for=\"wpforms-84-field_10\" class=\"wpforms-field-sublabel after \">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-84-field_10-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][10][last]\" aria-errormessage=\"wpforms-84-field_10-last-error\" required><label for=\"wpforms-84-field_10-last\" class=\"wpforms-field-sublabel after \">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-84-field_11-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-84-field_11\">Phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-84-field_11\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][11]\" aria-errormessage=\"wpforms-84-field_11-error\" required><\/div><div id=\"wpforms-84-field_12-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"12\"><fieldset><legend class=\"wpforms-field-label\">Date \/ Time <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-date-type-datepicker\"><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-84-field_12\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][12][date]\" aria-errormessage=\"wpforms-84-field_12-error\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><label for=\"wpforms-84-field_12\" class=\"wpforms-field-sublabel after \">Date<\/label><\/div><div class=\"wpforms-field-row-block\"><input type=\"text\" id=\"wpforms-84-field_12-time\" class=\"wpforms-field-date-time-time wpforms-timepicker wpforms-field-required\" data-time-format=\"g:i A\" data-step=\"30\" data-rule-time12h=\"true\" name=\"wpforms[fields][12][time]\" aria-errormessage=\"wpforms-84-field_12-time-error\" required><label for=\"wpforms-84-field_12-time\" class=\"wpforms-field-sublabel after \">Time<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-84-field_3-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"3\"><fieldset><legend class=\"wpforms-field-label\">Please write in your date of birth: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-date-dropdown-wrap wpforms-field-medium\"><select name=\"wpforms[fields][3][date][d]\" id=\"wpforms-84-field_3-day\" class=\"wpforms-field-date-time-date-day wpforms-field-required\" aria-label=\"Day\"  required><option value=\"\" class=\"placeholder\" selected disabled>DD<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><select name=\"wpforms[fields][3][date][m]\" id=\"wpforms-84-field_3-month\" class=\"wpforms-field-date-time-date-month wpforms-field-required\" aria-label=\"Month\"  required><option value=\"\" class=\"placeholder\" selected disabled>MM<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><select name=\"wpforms[fields][3][date][y]\" id=\"wpforms-84-field_3-year\" class=\"wpforms-field-date-time-date-year wpforms-field-required\" aria-label=\"Year\"  required><option value=\"\" class=\"placeholder\" selected disabled>YYYY<\/option><option value=\"2026\" >2026<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><option value=\"1925\" >1925<\/option><option value=\"1924\" >1924<\/option><option value=\"1923\" >1923<\/option><option value=\"1922\" >1922<\/option><option value=\"1921\" >1921<\/option><option value=\"1920\" >1920<\/option><\/select><\/div><\/fieldset><\/div><div id=\"wpforms-84-field_4-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"4\"><fieldset><legend class=\"wpforms-field-label\">Are you <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-84-field_4\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-84-field_4_1\" name=\"wpforms[fields][4]\" value=\"Male\" aria-errormessage=\"wpforms-84-field_4_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-84-field_4_1\">Male<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-84-field_4_2\" name=\"wpforms[fields][4]\" value=\"Female\" aria-errormessage=\"wpforms-84-field_4_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-84-field_4_2\">Female<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-84-field_5-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"5\"><fieldset><legend class=\"wpforms-field-label\">How often do you leak urine? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-84-field_5\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-84-field_5_1\" name=\"wpforms[fields][5]\" value=\"never\" aria-errormessage=\"wpforms-84-field_5_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-84-field_5_1\">never<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-84-field_5_2\" name=\"wpforms[fields][5]\" value=\"about once a week or less often\" aria-errormessage=\"wpforms-84-field_5_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-84-field_5_2\">about once a week or less often<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-84-field_5_6\" name=\"wpforms[fields][5]\" value=\"several times a day\" aria-errormessage=\"wpforms-84-field_5_6-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-84-field_5_6\">several times a day<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"radio\" id=\"wpforms-84-field_5_7\" name=\"wpforms[fields][5]\" value=\"about once a day\" aria-errormessage=\"wpforms-84-field_5_7-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-84-field_5_7\">about once a day<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"radio\" id=\"wpforms-84-field_5_8\" name=\"wpforms[fields][5]\" value=\"several times a day\" aria-errormessage=\"wpforms-84-field_5_8-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-84-field_5_8\">several times a day<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"radio\" id=\"wpforms-84-field_5_9\" name=\"wpforms[fields][5]\" value=\"all the time\" aria-errormessage=\"wpforms-84-field_5_9-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-84-field_5_9\">all the time<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-84-field_6-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"6\"><fieldset><legend class=\"wpforms-field-label\">We would like to know how much urine you think leaks.  How much urine do you usually leak (whether you wear protection or not)? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-84-field_6\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-84-field_6_1\" name=\"wpforms[fields][6]\" value=\"none\" aria-errormessage=\"wpforms-84-field_6_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-84-field_6_1\">none<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-84-field_6_2\" name=\"wpforms[fields][6]\" value=\"a small amount\" aria-errormessage=\"wpforms-84-field_6_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-84-field_6_2\">a small amount<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-84-field_6_6\" name=\"wpforms[fields][6]\" value=\"a moderate amount\" aria-errormessage=\"wpforms-84-field_6_6-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-84-field_6_6\">a moderate amount<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"radio\" id=\"wpforms-84-field_6_7\" name=\"wpforms[fields][6]\" value=\"a large amount\" aria-errormessage=\"wpforms-84-field_6_7-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-84-field_6_7\">a large amount<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-84-field_7-container\" class=\"wpforms-field wpforms-field-number-slider\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-84-field_7\">Overall, how much does leaking urine interfere with your everyday life?<\/label>\n<input\n\ttype=\"range\"\n\tid=\"wpforms-84-field_7\" class=\"wpforms-field-medium\" name=\"wpforms[fields][7]\" value=\"0\" aria-errormessage=\"wpforms-84-field_7-error\" aria-describedby=\"wpforms-84-field_7-description\"\t\tvalue=\"0\"\n\tmin=\"0\"\n\tmax=\"10\"\n\tstep=\"1\">\n\n<div class=\"wpforms-field-number-slider-hint\"\n\tdata-hint=\"Selected Value: {value}\">\n\tSelected Value: <b>0<\/b><\/div>\n<div id=\"wpforms-84-field_7-description\" class=\"wpforms-field-description\">Please ring a number between 0 (not at all) and 10 (a great deal)<\/div><\/div><div id=\"wpforms-84-field_9-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"9\"><fieldset><legend class=\"wpforms-field-label\">When does urine leak?  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-84-field_9\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-84-field_9_1\" name=\"wpforms[fields][9][]\" value=\"never \u2013 urine does not leak\" aria-errormessage=\"wpforms-84-field_9_1-error\" aria-describedby=\"wpforms-84-field_9-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-84-field_9_1\">never \u2013 urine does not leak<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-84-field_9_2\" name=\"wpforms[fields][9][]\" value=\"leaks before you can get to the toilet\" aria-errormessage=\"wpforms-84-field_9_2-error\" aria-describedby=\"wpforms-84-field_9-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-84-field_9_2\">leaks before you can get to the toilet<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-84-field_9_3\" name=\"wpforms[fields][9][]\" value=\"leaks when you cough or sneeze\" aria-errormessage=\"wpforms-84-field_9_3-error\" aria-describedby=\"wpforms-84-field_9-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-84-field_9_3\">leaks when you cough or sneeze<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-84-field_9_4\" name=\"wpforms[fields][9][]\" value=\"leaks when you are asleep\" aria-errormessage=\"wpforms-84-field_9_4-error\" aria-describedby=\"wpforms-84-field_9-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-84-field_9_4\">leaks when you are asleep<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-84-field_9_6\" name=\"wpforms[fields][9][]\" value=\"leaks when you are physically active\/exercising\" aria-errormessage=\"wpforms-84-field_9_6-error\" aria-describedby=\"wpforms-84-field_9-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-84-field_9_6\">leaks when you are physically active\/exercising<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-84-field_9_5\" name=\"wpforms[fields][9][]\" value=\"leaks when you have finished urinating and are dressed\" aria-errormessage=\"wpforms-84-field_9_5-error\" aria-describedby=\"wpforms-84-field_9-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-84-field_9_5\">leaks when you have finished urinating and are dressed<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-84-field_9_7\" name=\"wpforms[fields][9][]\" value=\"leaks for no obvious reason\" aria-errormessage=\"wpforms-84-field_9_7-error\" aria-describedby=\"wpforms-84-field_9-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-84-field_9_7\">leaks for no obvious reason<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-84-field_9_8\" name=\"wpforms[fields][9][]\" value=\"leaks all the time\" aria-errormessage=\"wpforms-84-field_9_8-error\" aria-describedby=\"wpforms-84-field_9-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-84-field_9_8\">leaks all the time<\/label><\/li><\/ul><div id=\"wpforms-84-field_9-description\" class=\"wpforms-field-description\">(Please tick all that apply to you)<\/div><\/fieldset><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"84\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"1\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-84\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img decoding=\"async\" src=\"https:\/\/appointment.srujanahospital.com\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\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>\n\t\t","protected":false},"excerpt":{"rendered":"<p>ICIQ-UI Short Form<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_canvas","meta":[],"_links":{"self":[{"href":"https:\/\/appointment.srujanahospital.com\/index.php\/wp-json\/wp\/v2\/pages\/100"}],"collection":[{"href":"https:\/\/appointment.srujanahospital.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/appointment.srujanahospital.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/appointment.srujanahospital.com\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/appointment.srujanahospital.com\/index.php\/wp-json\/wp\/v2\/comments?post=100"}],"version-history":[{"count":10,"href":"https:\/\/appointment.srujanahospital.com\/index.php\/wp-json\/wp\/v2\/pages\/100\/revisions"}],"predecessor-version":[{"id":170,"href":"https:\/\/appointment.srujanahospital.com\/index.php\/wp-json\/wp\/v2\/pages\/100\/revisions\/170"}],"wp:attachment":[{"href":"https:\/\/appointment.srujanahospital.com\/index.php\/wp-json\/wp\/v2\/media?parent=100"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}