{"id":3467,"date":"2018-07-13T08:38:35","date_gmt":"2018-07-13T08:38:35","guid":{"rendered":"http:\/\/dcrark.com\/dcrark\/distilling\/?page_id=3467"},"modified":"2018-11-02T17:46:34","modified_gmt":"2018-11-02T17:46:34","slug":"medical-form","status":"publish","type":"page","link":"http:\/\/dcrark.com\/dcrark\/distilling\/medical-form\/","title":{"rendered":"Therapeutic Form"},"content":{"rendered":"<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 14pt;\">Before filling the form out please register on this website, and fill in your address, this enables us to deal with any inquiries effectively.<\/span><\/p>\n<div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f3481-o1\" lang=\"en-GB\" dir=\"ltr\">\n<div class=\"screen-reader-response\" aria-live=\"polite\"><\/div>\n<form action=\"\/dcrark\/distilling\/wp-json\/wp\/v2\/pages\/3467#wpcf7-f3481-o1\" method=\"post\" class=\"wpcf7-form\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"3481\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.1.9\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_GB\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f3481-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<\/div>\n<p><label>Your login name <span class=\"wpcf7-form-control-wrap loginn\"><input type=\"text\" name=\"loginn\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text att\" id=\"loginn\" aria-invalid=\"false\" \/><\/span><\/label><\/p>\n<p><label> First Name <span class=\"wpcf7-form-control-wrap firstname\"><input type=\"text\" name=\"firstname\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text att\" id=\"firstname\" aria-invalid=\"false\" \/><\/span><\/label><\/p>\n<p><label> Middle Name <span class=\"wpcf7-form-control-wrap middlename\"><input type=\"text\" name=\"middlename\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text att\" id=\"middlename\" aria-invalid=\"false\" \/><\/span><\/label><\/p>\n<p><label> Last Name <span class=\"wpcf7-form-control-wrap lastname\"><input type=\"text\" name=\"lastname\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text att\" id=\"lastname\" aria-invalid=\"false\" \/><\/span><\/label><\/p>\n<p>If you are filling this form in with the medical user please provide your name below<\/p>\n<p><label> Helper Name <span class=\"wpcf7-form-control-wrap helpername\"><input type=\"text\" name=\"helpername\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text att\" id=\"helpername\" aria-invalid=\"false\" \/><\/span><\/label><\/p>\n<p><label> Date of Birth (e.g. dd-mm-yyyy) <span class=\"wpcf7-form-control-wrap dob\"><input type=\"text\" name=\"dob\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text att\" id=\"dob\" aria-invalid=\"false\" \/><\/span><\/label><\/p>\n<p><label> House Number or Name  <span class=\"wpcf7-form-control-wrap housen\"><input type=\"text\" name=\"housen\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text att\" id=\"housen\" aria-invalid=\"false\" \/><\/span><\/label><\/p>\n<p><label> Street <span class=\"wpcf7-form-control-wrap street\"><input type=\"text\" name=\"street\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text att\" id=\"street\" aria-invalid=\"false\" \/><\/span><\/label><\/p>\n<p><label> Locality <span class=\"wpcf7-form-control-wrap locality\"><input type=\"text\" name=\"locality\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text att\" id=\"locality\" aria-invalid=\"false\" \/><\/span><\/label><\/p>\n<p><label> City <span class=\"wpcf7-form-control-wrap city\"><input type=\"text\" name=\"city\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text att\" id=\"city\" aria-invalid=\"false\" \/><\/span><\/label><\/p>\n<p><label> County \/State \/ Province \/ Region <span class=\"wpcf7-form-control-wrap county\"><input type=\"text\" name=\"county\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text att\" id=\"county\" aria-invalid=\"false\" \/><\/span><\/label><\/p>\n<p><label> Country <span class=\"wpcf7-form-control-wrap country\"><input type=\"text\" name=\"country\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text att\" id=\"country\" aria-invalid=\"false\" \/><\/span><\/label><\/p>\n<p><label> ZIP \/ Postal Code <span class=\"wpcf7-form-control-wrap postcode\"><input type=\"text\" name=\"postcode\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text att\" id=\"postcode\" aria-invalid=\"false\" \/><\/span><\/label><\/p>\n<p><label> Telephone (e.g. international dialing code, +44 161 298 0298) <span class=\"wpcf7-form-control-wrap telephone\"><input type=\"text\" name=\"telephone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text att\" id=\"telephone\" aria-invalid=\"false\" \/><\/span><\/label><\/p>\n<p><label> Your Email Address  <span class=\"wpcf7-form-control-wrap email\"><input type=\"text\" name=\"email\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text att\" id=\"email\" aria-invalid=\"false\" \/><\/span><\/label><\/p>\n<p><label> Your General Practitioner's or Doctor's Name <span class=\"wpcf7-form-control-wrap drname\"><input type=\"text\" name=\"drname\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text att\" id=\"drname\" aria-invalid=\"false\" \/><\/span><\/label><\/p>\n<p><label> Your weight in Kg <span class=\"wpcf7-form-control-wrap weight\"><input type=\"text\" name=\"weight\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text att\" id=\"weight\" aria-invalid=\"false\" \/><\/span><\/label><\/p>\n<p><label> Your height <span class=\"wpcf7-form-control-wrap height\"><input type=\"text\" name=\"height\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text att\" id=\"height\" aria-invalid=\"false\" \/><\/span><\/label><\/p>\n<p><label> Your Occupation <span class=\"wpcf7-form-control-wrap job\"><input type=\"text\" name=\"job\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text att\" id=\"job\" aria-invalid=\"false\" \/><\/span><\/label><\/p>\n<p><label> How many children do you have ? <span class=\"wpcf7-form-control-wrap children\"><input type=\"text\" name=\"children\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text att\" id=\"children\" aria-invalid=\"false\" \/><\/span><\/label><\/p>\n<p>These notes are prompts, please add anything else that you have experienced even if you feel it may not be relevant.<\/p>\n<p><label> 1. Previous Cannabis Use<br \/>\n<span class=\"wpcf7-form-control-wrap q1\"><textarea name=\"q1\" cols=\"160\" rows=\"1\" maxlength=\"160\" class=\"wpcf7-form-control wpcf7-textarea att\" id=\"q1\" aria-invalid=\"false\"><\/textarea><\/span><\/label><br \/>\n<label>Characters Typed <span class=\"wpcf7-character-count up\" data-target-name=\"q1\" data-starting-value=\"0\" data-current-value=\"0\" data-maximum-value=\"160\">0<\/span>  (max 160)<\/label><\/p>\n<p><label> 2. Presenting complaint (eg type of cancer, primary location, where it has spread to and any other conditions)<br \/>\n<span class=\"wpcf7-form-control-wrap q2\"><textarea name=\"q2\" cols=\"160\" rows=\"1\" maxlength=\"160\" class=\"wpcf7-form-control wpcf7-textarea att\" id=\"q2\" aria-invalid=\"false\"><\/textarea><\/span><\/label><label>Characters Typed <span class=\"wpcf7-character-count up\" data-target-name=\"q2\" data-starting-value=\"0\" data-current-value=\"0\" data-maximum-value=\"160\">0<\/span>  (max 160)<\/label><\/p>\n<p><label> 2a. Current medicine used.<br \/>\n<span class=\"wpcf7-form-control-wrap q2a\"><textarea name=\"q2a\" cols=\"160\" rows=\"1\" class=\"wpcf7-form-control wpcf7-textarea att\" aria-invalid=\"false\"><\/textarea><\/span><\/label><br \/>\n<label>Characters Typed <span class=\"wpcf7-character-count up\" data-target-name=\"q2a\" data-starting-value=\"0\" data-current-value=\"0\">0<\/span>  (max 160)<\/label><\/p>\n<p><label> 3. Past medical History (operations, illnesses, allergies, accidents, childhood illnesses etc)<br \/>\n<span class=\"wpcf7-form-control-wrap q3\"><textarea name=\"q3\" cols=\"160\" rows=\"1\" maxlength=\"160\" class=\"wpcf7-form-control wpcf7-textarea att\" id=\"q3\" aria-invalid=\"false\"><\/textarea><\/span><\/label><br \/>\n<label>Characters Typed <span class=\"wpcf7-character-count up\" data-target-name=\"q3\" data-starting-value=\"0\" data-current-value=\"0\" data-maximum-value=\"160\">0<\/span>  (max 160)<\/label><\/p>\n<p><label> 4. Drug history (immunisations, painkillers, vaccinations, contraceptives, vitamins and supplements)<br \/>\n<span class=\"wpcf7-form-control-wrap q4\"><textarea name=\"q4\" cols=\"160\" rows=\"1\" maxlength=\"160\" class=\"wpcf7-form-control wpcf7-textarea att\" id=\"q4\" aria-invalid=\"false\"><\/textarea><\/span><\/label><br \/>\n<label>Characters Typed <span class=\"wpcf7-character-count up\" data-target-name=\"q4\" data-starting-value=\"0\" data-current-value=\"0\" data-maximum-value=\"160\">0<\/span>  (max 160)<\/label><\/p>\n<p><label> 5. Other complementary medical support (other therapies you have used or currently use)<br \/>\n<span class=\"wpcf7-form-control-wrap q5\"><textarea name=\"q5\" cols=\"160\" rows=\"1\" maxlength=\"160\" class=\"wpcf7-form-control wpcf7-textarea att\" id=\"q5\" aria-invalid=\"false\"><\/textarea><\/span><\/label><br \/>\n<label>Characters Typed <span class=\"wpcf7-character-count up\" data-target-name=\"q5\" data-starting-value=\"0\" data-current-value=\"0\" data-maximum-value=\"160\">0<\/span>  (max 160)<\/label><\/p>\n<p><label> 6. Family history (hereditary conditions, significant relationships, children)<br \/>\n<span class=\"wpcf7-form-control-wrap q6\"><textarea name=\"q6\" cols=\"160\" rows=\"1\" maxlength=\"160\" class=\"wpcf7-form-control wpcf7-textarea att\" id=\"q6\" aria-invalid=\"false\"><\/textarea><\/span><\/label><br \/>\n<label>Characters Typed <span class=\"wpcf7-character-count up\" data-target-name=\"q6\" data-starting-value=\"0\" data-current-value=\"0\" data-maximum-value=\"160\">0<\/span>  (max 160)<\/label><\/p>\n<p><label> 7. Social history (smoking, drugs, drinking, exercise, work, hobbies)<br \/>\n<span class=\"wpcf7-form-control-wrap q7\"><textarea name=\"q7\" cols=\"160\" rows=\"1\" maxlength=\"160\" class=\"wpcf7-form-control wpcf7-textarea att\" id=\"q7\" aria-invalid=\"false\"><\/textarea><\/span><\/label><br \/>\n<label>Characters Typed <span class=\"wpcf7-character-count up\" data-target-name=\"q7\" data-starting-value=\"0\" data-current-value=\"0\" data-maximum-value=\"160\">0<\/span>  (max 160)<\/label><\/p>\n<p><label> 8. General: do you feel tired, emotional, weak, easily catch illnesses that are going around, take a long time to recover from<br \/>\nillnesses, feel tired after meals, crave unusual foods?<br \/>\n<span class=\"wpcf7-form-control-wrap q8\"><textarea name=\"q8\" cols=\"160\" rows=\"1\" maxlength=\"160\" class=\"wpcf7-form-control wpcf7-textarea att\" id=\"q8\" aria-invalid=\"false\"><\/textarea><\/span><\/label><br \/>\n<label>Characters Typed <span class=\"wpcf7-character-count up\" data-target-name=\"q8\" data-starting-value=\"0\" data-current-value=\"0\" data-maximum-value=\"160\">0<\/span>  (max 160)<\/label><\/p>\n<p><label> 9. Cardiovascular system: have you ever experienced chest pain, fainting, palpitations, swelling of your ankles, varicose veins\/piles, and cold extremities?<br \/>\nHave you ever been treated for a cardiovascular related condition?<br \/>\n<span class=\"wpcf7-form-control-wrap q9\"><textarea name=\"q9\" cols=\"160\" rows=\"1\" maxlength=\"160\" class=\"wpcf7-form-control wpcf7-textarea att\" id=\"q9\" aria-invalid=\"false\"><\/textarea><\/span><\/label><br \/>\n<label>Characters Typed <span class=\"wpcf7-character-count up\" data-target-name=\"q9\" data-starting-value=\"0\" data-current-value=\"0\" data-maximum-value=\"160\">0<\/span>  (max 160)<\/label><\/p>\n<p><label> 10. Respiratory system: do you regularly suffer with catarrh, earache, sore throat, and coughs?<br \/>\nDo you have any other respiratory conditions e.g. asthma?<br \/>\n<span class=\"wpcf7-form-control-wrap q10\"><textarea name=\"q10\" cols=\"160\" rows=\"1\" maxlength=\"160\" class=\"wpcf7-form-control wpcf7-textarea att\" id=\"q10\" aria-invalid=\"false\"><\/textarea><\/span><\/label><br \/>\n<label>Characters Typed <span class=\"wpcf7-character-count up\" data-target-name=\"q10\" data-starting-value=\"0\" data-current-value=\"0\" data-maximum-value=\"160\">0<\/span>  (max 160)<\/label><\/p>\n<p><label> 11. Gastrointestinal system: have you ever experienced problems with your digestion, your teeth, with constipation and\/or<br \/>\ndiarrhoea, abdominal pain, bloating, vomiting? How is your appetite? Are you happy with your weight?<br \/>\n<span class=\"wpcf7-form-control-wrap q11\"><textarea name=\"q11\" cols=\"160\" rows=\"1\" maxlength=\"160\" class=\"wpcf7-form-control wpcf7-textarea att\" id=\"q11\" aria-invalid=\"false\"><\/textarea><\/span><\/label><br \/>\n<label>Characters Typed <span class=\"wpcf7-character-count up\" data-target-name=\"q11\" data-starting-value=\"0\" data-current-value=\"0\" data-maximum-value=\"160\">0<\/span>  (max 160)<\/label><\/p>\n<p><label> 12. Urinary system: do you need to urinate often, is there urgency, poor stream or difficulty starting?<br \/>\nDo you experience loin pain? Do you suffer from recurring cystitis or kidney stones?<br \/>\n<span class=\"wpcf7-form-control-wrap q12\"><textarea name=\"q12\" cols=\"160\" rows=\"1\" maxlength=\"160\" class=\"wpcf7-form-control wpcf7-textarea att\" id=\"q12\" aria-invalid=\"false\"><\/textarea><\/span><\/label><br \/>\n<label>Characters Typed <span class=\"wpcf7-character-count up\" data-target-name=\"q12\" data-starting-value=\"0\" data-current-value=\"0\" data-maximum-value=\"160\">0<\/span>  (max 160)<\/label><\/p>\n<p><label> 13. Nervous system: do suffer from sleep disturbance, headaches, visual disturbances, hearing loss\/ tinnitus, dizziness, vertigo,<br \/>\nfainting, fits, poor memory, weakness, tremor, pins and needles, cold extremities? Do you experience depression or other mood changes?<br \/>\n<span class=\"wpcf7-form-control-wrap q13\"><textarea name=\"q13\" cols=\"160\" rows=\"1\" maxlength=\"160\" class=\"wpcf7-form-control wpcf7-textarea att\" id=\"q13\" aria-invalid=\"false\"><\/textarea><\/span><\/label><br \/>\n<label>Characters Typed <span class=\"wpcf7-character-count up\" data-target-name=\"q13\" data-starting-value=\"0\" data-current-value=\"0\" data-maximum-value=\"160\">0<\/span>  (max 160)<\/label><\/p>\n<p><label> 14. Gynaecological system: what age did you start to menstruate, are you still menstruating or peri\/post menopausal, do you suffer from PMS?<br \/>\n<span class=\"wpcf7-form-control-wrap q14\"><textarea name=\"q14\" cols=\"160\" rows=\"1\" maxlength=\"160\" class=\"wpcf7-form-control wpcf7-textarea att\" id=\"q14\" aria-invalid=\"false\"><\/textarea><\/span><\/label><br \/>\n<label>Characters Typed <span class=\"wpcf7-character-count up\" data-target-name=\"q14\" data-starting-value=\"0\" data-current-value=\"0\" data-maximum-value=\"160\">0<\/span>  (max 160)<\/label><\/p>\n<p><label> 15. Muscular skeletal system: do you suffer from joint pain or stiffness, joint swelling, lumps\/bumps on joints, pain to you back or neck?<br \/>\nHave you ever suffered from whiplash or concussion?  Do you have carpal tunnel syndrome?<br \/>\n<span class=\"wpcf7-form-control-wrap q15\"><textarea name=\"q15\" cols=\"160\" rows=\"1\" maxlength=\"160\" class=\"wpcf7-form-control wpcf7-textarea att\" id=\"q15\" aria-invalid=\"false\"><\/textarea><\/span><\/label><br \/>\n<label>Characters Typed <span class=\"wpcf7-character-count up\" data-target-name=\"q15\" data-starting-value=\"0\" data-current-value=\"0\" data-maximum-value=\"160\">0<\/span>  (max 160)<\/label><\/p>\n<p><label> 16. Skin: do you have acne, rashes, fungal infections, itching, herpes, extremely dry skin, hair loss?<br \/>\n<span class=\"wpcf7-form-control-wrap q16\"><textarea name=\"q16\" cols=\"160\" rows=\"1\" maxlength=\"160\" class=\"wpcf7-form-control wpcf7-textarea att\" id=\"q16\" aria-invalid=\"false\"><\/textarea><\/span><\/label><br \/>\n<label>Characters Typed <span class=\"wpcf7-character-count up\" data-target-name=\"q16\" data-starting-value=\"0\" data-current-value=\"0\" data-maximum-value=\"160\">0<\/span>  (max 160)<\/label><\/p>\n<p><label> 17. Allergies:<br \/>\n<span class=\"wpcf7-form-control-wrap q17\"><textarea name=\"q17\" cols=\"160\" rows=\"1\" maxlength=\"160\" class=\"wpcf7-form-control wpcf7-textarea att\" id=\"q17\" aria-invalid=\"false\"><\/textarea><\/span><\/label><br \/>\n<label>Characters Typed <span class=\"wpcf7-character-count up\" data-target-name=\"q17\" data-starting-value=\"0\" data-current-value=\"0\" data-maximum-value=\"160\">0<\/span>  (max 160)<\/label><\/p>\n<p><label> Please attach any blood tests or details of other tests that you feel may be relevant.<br \/>\n<\/label><\/p>\n<p><label> Please click the \"Browse Button\" to Attach your PDF Files (max file size 8mb)<br \/>\n<span class=\"wpcf7-form-control-wrap pdffile\"><input type=\"file\" name=\"pdffile\" size=\"40\" class=\"wpcf7-form-control wpcf7-file\" id=\"file\" accept=\".pdf\" aria-invalid=\"false\" \/><\/span><br \/>\n<\/label><\/p>\n<p>by submitting your details you are agreeing to the terms and conditions of darkcity<\/p>\n<p><input type=\"submit\" value=\"send\" class=\"wpcf7-form-control wpcf7-submit att\" id=\"submit\" \/><\/p>\n<div class=\"wpcf7-response-output wpcf7-display-none\" aria-hidden=\"true\"><\/div><\/form><\/div>\n","protected":false},"excerpt":{"rendered":"<p>Before filling the form out please register on this website, and fill in your address, this enables us to deal with any inquiries effectively.<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page-fullwidth.php","meta":{"footnotes":""},"class_list":["post-3467","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"http:\/\/dcrark.com\/dcrark\/distilling\/wp-json\/wp\/v2\/pages\/3467","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/dcrark.com\/dcrark\/distilling\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"http:\/\/dcrark.com\/dcrark\/distilling\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"http:\/\/dcrark.com\/dcrark\/distilling\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"http:\/\/dcrark.com\/dcrark\/distilling\/wp-json\/wp\/v2\/comments?post=3467"}],"version-history":[{"count":0,"href":"http:\/\/dcrark.com\/dcrark\/distilling\/wp-json\/wp\/v2\/pages\/3467\/revisions"}],"wp:attachment":[{"href":"http:\/\/dcrark.com\/dcrark\/distilling\/wp-json\/wp\/v2\/media?parent=3467"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}