{"id":39137,"date":"2024-11-26T14:11:30","date_gmt":"2024-11-26T19:11:30","guid":{"rendered":"https:\/\/dormalab.com\/?page_id=39137"},"modified":"2026-02-03T09:13:28","modified_gmt":"2026-02-03T14:13:28","slug":"questionnaire-medical","status":"publish","type":"page","link":"https:\/\/dormalab.com\/fr\/questionnaire-medical\/","title":{"rendered":"Questionnaire m\u00e9dical"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"39137\" class=\"elementor elementor-39137 elementor-39126\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-e3e57a6 e-flex e-con-boxed e-con e-parent\" data-id=\"e3e57a6\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-a85166d elementor-widget elementor-widget-html\" data-id=\"a85166d\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<!doctype html>\n<html lang=\"fr\">\n\n\n<head>\n\n    <!-- Required meta tags -->\n    <meta charset=\"utf-8\">\n    <meta name=\"viewport\" content=\"width=device-width, initial-scale=1\">\n\n    <!-- Bootstrap CSS -->\n    <link href=\"https:\/\/cdn.jsdelivr.net\/npm\/bootstrap@5.0.1\/dist\/css\/bootstrap.min.css\" rel=\"stylesheet\"\n          integrity=\"sha384-+0n0xVW2eSR5OomGNYDnhzAbDsOXxcvSN1TPprVMTNDbiYZCxYbOOl7+AMvyTG2x\" crossorigin=\"anonymous\">\n    <script src=\"https:\/\/ajax.googleapis.com\/ajax\/libs\/jquery\/3.7.0\/jquery.min.js\"><\/script>\n    <link rel=\"stylesheet\" href=\"https:\/\/cdnjs.cloudflare.com\/ajax\/libs\/font-awesome\/5.15.3\/css\/all.min.css\"\n          integrity=\"sha512-iBBXm8fW90+nuLcSKlbmrPcLa0OT92xO1BIsZ+ywDWZCvqsWgccV3gFoRBv0z+8dLJgyAHIhR35VZc2oM\/gI1w==\"\n          crossorigin=\"anonymous\" referrerpolicy=\"no-referrer\"\/>\n    <link rel=\"stylesheet\"\n          href=\"https:\/\/cdnjs.cloudflare.com\/ajax\/libs\/bootstrap-datepicker\/1.10.0\/css\/bootstrap-datepicker.min.css\"\/>\n    <script src=\"https:\/\/cdnjs.cloudflare.com\/ajax\/libs\/bootstrap-datepicker\/1.10.0\/js\/bootstrap-datepicker.min.js\">\n    <\/script>\n    <script>\n        jQuery.noConflict();\n    <\/script>\n    <script src=\"https:\/\/cdn.jsdelivr.net\/npm\/sweetalert2@11\"><\/script>\n\n\n    <title>Questionnaire<\/title>\n    <style>\n                form input[type=\"text\"],\nform input[type=\"email\"],\nform input[type=\"password\"],\nform input[type=\"tel\"],\nform input[type=\"phone\"], \/* Targets your specific case *\/\nform input[type=\"number\"],\nform input[type=\"url\"],\nform input[type=\"search\"],\nform input[type=\"date\"],\nform input[type=\"datetime-local\"],\nform input[type=\"month\"],\nform input[type=\"week\"],\nform input[type=\"time\"],\nform input[type=\"color\"],\nform select,\nform textarea {\n    background-color: white !important;\n    color: black;\n    border: 1px solid #ccc; \/* Optional: Adds a subtle border *\/\n    padding: 10px; \/* Optional: Adds padding for better usability *\/\n    border-radius: 4px; \/* Optional: Adds rounded corners *\/\n    box-shadow: none; \/* Removes any default shadow *\/\n    padding:10px !important;\n}\n\/* General checkbox styling *\/\n\/* General checkbox styling *\/\nform input[type=\"checkbox\"],\nform .form-check-input {\n    width: 20px; \/* Standard size *\/\n    height: 20px; \/* Standard size *\/\n    background-color: white; \/* Ensure white background *\/\n    border: 1px solid #ccc; \/* Subtle border *\/\n    border-radius: 3px; \/* Optional: Slightly rounded corners *\/\n    cursor: pointer; \/* Pointer cursor for interactivity *\/\n    -webkit-appearance: checkbox; \/* Restore default checkbox appearance for WebKit browsers *\/\n    -moz-appearance: checkbox; \/* Restore default checkbox appearance for Mozilla browsers *\/\n    appearance: checkbox; \/* Restore default checkbox appearance *\/\n}\n\n        p {\n            font-weight: 600;\n        }\n\n        .astrisc {\n            color: red;\n        }\n\n        .other-section {\n            display: none;\n        }\n\n        .error-message {\n            width: 100%;\n            margin-top: .25rem;\n            font-size: .875em;\n            color: #dc3545;\n        }\n\n        .form-control.is-invalid,\n        .was-validated .form-control:invalid {\n            border-color: #dc3545 !important;\n            padding-right: calc(1.5em + .75rem);\n            background-image: none !important;\n            background-repeat: no-repeat !important;\n            background-position: right calc(.375em + .1875rem) center !important;\n            background-size: calc(.75em + .375rem) calc(.75em + .375rem) !important;\n        }\n\n        \/* Erreur au niveau du groupe de cases \u00e0 cocher *\/\n        .has-checkbox-error {\n            border: 1px dashed #dc3545;\n            padding: 10px;\n            border-radius: 8px;\n            background-color: #fff8f8;\n        }\n        .error-message.group { margin-top: 6px; }\n\n        td {\n            width: 25%;\n        }\n\n        \/* autocomplete styles *\/\n\n        .autocomplete {\n            \/*the container must be positioned relative:*\/\n            position: relative;\n            display: inline-block;\n        }\n\n        .autocomplete-items {\n            position: absolute;\n            border: 1px solid #d4d4d4;\n            border-bottom: none;\n            border-top: none;\n            z-index: 99;\n            \/*position the autocomplete items to be the same width as the container:*\/\n            top: 100%;\n            left: 0;\n            right: 0;\n        }\n\n        .autocomplete-items div {\n            padding: 10px;\n            cursor: pointer;\n            background-color: #fff;\n            border-bottom: 1px solid #d4d4d4;\n        }\n\n        .autocomplete-items div:hover {\n            \/*when hovering an item:*\/\n            background-color: #e9e9e9;\n        }\n\n        .autocomplete-active {\n            \/*when navigating through the items using the arrow keys:*\/\n            background-color: DodgerBlue !important;\n            color: #ffffff;\n        }\n\n        .question {\n            margin-top: 25px;\n        }\n\n        .question > p {\n            margin-bottom: 0px;\n        }\n\n        .emergency-section {\n            margin-top: 25px;\n        }\n\n        .form-label {\n            margin-bottom: .5rem;\n            font-weight: 600;\n            margin-top: 15px;\n        }\n\n        .section {\n            background-color: #0083ff12;\n            border-radius: 15px;\n            padding: 20px;\n            margin-top: 5px;\n            margin-bottom: 5px;\n        }\n\n        .fa-calendar {\n            height: 100%;\n            cursor: pointer;\n        }\n\n        .datepicker table tr td,\n        .datepicker table tr th {\n            width: 2.5em;\n            height: 2.0em;\n            text-align: center;\n            vertical-align: middle;\n            border-radius: 0 !important;\n        }\n\n        .swal2-container .swal2-confirm.btn.btn-primary:focus {\n            outline: none !important;\n            box-shadow: none !important;\n        }\n\n        \/* end autocomplete styles *\/\n    <\/style>\n\n    <!--    StopBang-->\n    <style>\n        .error {\n            border: 1px solid #dc3545 !important;\n            background-color: #ffe6e6;\n        }\n\n        #height-error {\n            background-color: transparent !important;\n            border: none !important;\n            box-shadow: none !important;\n            outline: none !important;\n            font-size: 14px;\n        }\n\n        #height-error.invalid-feedback {\n            margin-top: 0 !important;\n            margin-bottom: 10px !important;\n            padding: 0 !important;\n        }\n\n        .OSAQuizeResultWrapper {\n            display: none;\n        }\n\n        .OSAQuizeWrapper {\n            width: 100%;\n            max-width: 600 px;\n            margin: auto;\n            font: 400 14 px 'Calibri', 'Arial';\n        }\n\n        .OSAQuizeWrapper .OSAQuizeResultWrapper {\n            width: 100%;\n            border-bottom: 1px solid #eeeeee;\n            border-top: 1px solid #eeeeee;\n        }\n\n        .OSAQuizeWrapper .submitActionZone {\n            text-align: right;\n            margin: 20px 0px;\n        }\n\n        .OSAQuizeWrapper .submitBtn {\n            background-color: rgb(16, 111, 173);\n            border: none;\n            border-radius: 5px;\n            color: white;\n            padding: 16px 40px;\n            text-align: center;\n            text-decoration: none;\n            display: inline-block;\n            font-size: 16px;\n            margin: 4px 2px;\n            -webkit-transition-duration: 0.4s;\n            \/* Safari *\/\n            transition-duration: 0.4s;\n            cursor: pointer;\n        }\n\n        .singleQuestion {\n            overflow: hidden;\n            line-height: 1.2rem;\n            padding: 10px 0px;\n            border-bottom: 1px solid #eeeeee;\n        }\n\n        .singleQuestion .inputWrapper,\n        .questionWrapper {\n            width: 50%;\n            float: left;\n        }\n\n        .singleQuestion .questionTitle {\n            color: black;\n            font-weight: 600;\n        }\n\n        .singleQuestion .quesitonDesc {\n            color: #555555;;\n        }\n\n        .inputWrapper div {\n            box-sizing: border-box;\n            background-color: #f1f1f1;\n            \/* Green background *\/\n            border-bottom: 1px solid #aaaaaa;\n            \/* Green border *\/\n            border-top: 1px solid #aaaaaa;\n            \/* Green border *\/\n            border-right: 1px solid #aaaaaa;\n            \/* Green border *\/\n            padding: 10px 24px;\n            \/* Some padding *\/\n            cursor: pointer;\n            \/* Pointer\/hand icon *\/\n            float: left;\n            width: 50%;\n        }\n\n        .inputWrapper div:first-of-type {\n            border-left: 1px solid #aaaaaa;\n            \/* Green border *\/\n            border-top-left-radius: 4px;\n            border-bottom-left-radius: 4px;\n        }\n\n        .inputWrapper div:last-of-type {\n            border-right: 1px solid #aaaaaa;\n            \/* Green border *\/\n            border-top-right-radius: 4px;\n            border-bottom-right-radius: 4px;\n        }\n\n        .inputWrapper .selectedBtn {\n            background-color: #0d6efd;\n            color: white;\n        }\n\n        .inputWrapper .bmi-filed-wrapper {\n            width: 100%;\n            padding: 0px;\n            display: flex;\n            flex-direction: row;\n            box-sizing: border-box;\n            margin-bottom: 10px;\n            overflow: hidden;\n            border: 1px solid #aaaaaa;;\n            border-radius: 4px;\n        }\n\n        .inputWrapper .bmi-filed-wrapper input {\n            margin: 0px;\n            \/* border: none; *\/\n            padding: 10px 10px;\n            display: block;\n            border-radius: 4px;\n            flex-grow: initial;\n            width: 70%;\n        }\n\n        .inputWrapper .bmi-filed-wrapper div {\n            margin: 0px;\n            padding: 10px 10px;\n            width: 30%;\n            display: block;\n            border: none;\n            border-top-right-radius: 3px;\n            border-bottom-right-radius: 3px;\n            background-color: #f1f1f1\n        }\n\n        .inputWrapper .bmi-filed-wrapper div:hover {\n            cursor: pointer;\n            background-color: #e1e1e1;\n        }\n\n        .inputWrapper .bmi-result {\n            background: none;\n            border: none;\n            float: right;\n            padding: 5px 10px;\n        }\n\n        @media screen and (max-width: 45.5em) {\n\n            .singleQuestion .inputWrapper,\n            .questionWrapper {\n                width: 100%;\n                float: left;\n            }\n        }\n    <\/style>\n\n    <!--    Epworth-->\n    <style>\n        .epworthQuizeResultWrapper {\n            display: none;\n        }\n\n        div.sleepinessQuizeWrapper {\n            max-width: 1000 px;\n            margin: auto;\n            font: 400 14 px 'Calibri', 'Arial';\n        }\n\n        table.sleepinessQuize {\n            border-spacing: 0;\n            border-collapse: separate; \n            background: white;\n            border-radius: 6px; \n            overflow: hidden; \n            width: 100%;\n            margin: 0 auto;\n            position: relative;\n        }\n\n        table.sleepinessQuize .quizeQuestion {\n            text-align: left;\n        }\n\n\n        table.sleepinessQuize * {\n            position: relative;\n        }\n\n        table.sleepinessQuize td,\n        table.sleepinessQuize th {\n            padding-left: 8px;\n            width: auto;\n        }\n\n        td input {\n            display: inline-block;\n            padding-left: 10px;\n            background-color: rgb(204, 204, 204);\n            cursor: pointer;\n        }\n\n        td input:hover {\n            background-color: rgb(240, 238, 238);\n            text-align: center;\n            cursor: pointer;\n        }\n\n        table.sleepinessQuize thead tr {\n            height: 60px;\n            background: #f1f1f1f1;\n            font-size: 16px;\n        }\n\n        table.sleepinessQuize tbody tr {\n            height: 48px;\n            border-bottom: 1px solid #E3F1D5;\n        }\n\n        table.sleepinessQuize tbody tr:last-child {\n            border-bottom: none;\n        }\n\n        table.sleepinessQuize tbody td {\n            border-bottom: 1px solid #E3F1D5;\n        }\n\n        table.sleepinessQuize td,\n        table.sleepinessQuize th {\n            text-align: center;\n        }\n\n        table.sleepinessQuize td.l,\n        table.sleepinessQuize th.l {\n            text-align: right;\n        }\n\n        table.sleepinessQuize td.c,\n        table.sleepinessQuize th.c {\n            text-align: center;\n        }\n\n        table.sleepinessQuize td.r,\n        table.sleepinessQuize th.r {\n            text-align: center;\n        }\n\n        table.sleepinessQuize th:first {\n            text-align: right;\n        }\n\n        div.sleepinessQuizeWrapper .submitBtn {\n            background-color: #FFED86;\n            \/* Green *\/\n            border: none;\n            border-radius: 5px;\n            color: black;\n            padding: 16px 40px;\n            text-align: center;\n            text-decoration: none;\n            display: inline-block;\n            font-size: 16px;\n            margin: 4px 2px;\n            -webkit-transition-duration: 0.4s;\n            \/* Safari *\/\n            transition-duration: 0.4s;\n            cursor: pointer;\n        }\n\n        div.sleepinessQuizeWrapper .submitActionZone {\n            text-align: right;\n            margin-bottom: 20px;\n        }\n\n        div.sleepinessQuizeWrapper button:hover {\n            background-color: rgb(240, 222, 122);\n        }\n\n        .sleepinessQuizeErrorMsg {\n            color: #D8000C;\n            margin-top: 10px;\n            margin-bottom: 10px;\n            visibility: hidden;\n        }\n\n        .epworthQuizeResultWrapper {\n            width: 100%;\n            border-bottom: 1px solid #E3F1D5;\n            border-top: 1px solid #E3F1D5;\n        }\n\n\n        @media screen and (max-width: 45.5em) {\n            table.sleepinessQuize {\n                display: block;\n            }\n\n            table.sleepinessQuize > *,\n            table.sleepinessQuize tr,\n            table.sleepinessQuize td,\n            table.sleepinessQuize th {\n                display: block;\n            }\n\n            table.sleepinessQuize thead {\n                display: none;\n            }\n\n            table.sleepinessQuize tbody tr {\n                height: auto;\n                padding: 18px 0;\n            }\n\n            table.sleepinessQuize tbody tr td {\n                padding-left: 45%;\n                margin-bottom: 16px;\n                width: 100%;\n                font-size: 12px;\n                line-height: 1;\n            }\n\n            table.sleepinessQuize tbody tr td:last-child {\n                margin-bottom: 0;\n            }\n\n            table.sleepinessQuize tbody tr td:before {\n                position: absolute;\n                font-weight: 700;\n                width: 40%;\n                left: 10px;\n                top: 0;\n            }\n\n            table.sleepinessQuize tbody tr td:nth-child(1):before {\n                content: \"\";\n            }\n\n            table.sleepinessQuize tbody tr td:nth-child(2):before {\n                content: \"No chance of dozing\t\";\n            }\n\n            table.sleepinessQuize tbody tr td:nth-child(3):before {\n                content: \"Slight chance of dozing\t\";\n            }\n\n            table.sleepinessQuize tbody tr td:nth-child(4):before {\n                content: \"Moderate chance of dozing\t\";\n            }\n\n            table.sleepinessQuize tbody tr td:nth-child(5):before {\n                content: \"High chance of dozing\";\n            }\n        }\n\n        body {\n            padding: 20px;\n        }\n\n        blockquote {\n            color: white;\n            text-align: center;\n        }\n    <\/style>\n\n\n<\/head>\n\n<body>\n<!-- Optional JavaScript; choose one of the two! -->\n\n<!-- Option 1: Bootstrap Bundle with Popper -->\n<script src=\"https:\/\/cdn.jsdelivr.net\/npm\/bootstrap@5.0.1\/dist\/js\/bootstrap.bundle.min.js\"\n        integrity=\"sha384-gtEjrD\/SeCtmISkJkNUaaKMoLD0\/\/ElJ19smozuHV6z3Iehds+3Ulb9Bn9Plx0x4\" crossorigin=\"anonymous\">\n<\/script>\n<script>\n    \/\/test params\n    \/\/?formType=travel&questionnaireId=a075e000000lYd9AAE\n    var countryArray = [];\n    var countryIds = [];\n    let selectedDoctorId;\n    let selectedDentistId;\n\n    async function dataSubmit() {\n        console.log('submitting data');\n\n        function isValidDate(dateString) {\n            var regEx = \/^\\d{4}-\\d{2}-\\d{2}$\/;\n            if (!dateString.match(regEx)) return false; \/\/ Invalid format\n            var d = new Date(dateString);\n            var dNum = d.getTime();\n            if (!dNum && dNum !== 0) return false; \/\/ NaN value, Invalid date\n            return d.toISOString().slice(0, 10) === dateString;\n        }\n\n        function isValidBirthdate(dateString) {\n            if (!isValidDate(dateString)) return false;\n            var d = new Date(dateString);\n            var today = new Date();\n            var year = d.getFullYear();\n            var currentYear = today.getFullYear();\n            var minYear = currentYear - 150; \/\/ Maximum age of 150 years\n            \n            \/\/ Check if date is in the future\n            if (d > today) return false;\n            \n            \/\/ Check if year is reasonable (not before 1900 and not more than 150 years ago)\n            if (year < 1900 || year < minYear) return false;\n            \n            return true;\n        }\n\n        \/\/validate birthdate first\n        var birthdateValue = jQuery('#birthdate').val();\n        if (!isValidDate(birthdateValue)) {\n            alert(\"Votre date de naissance doit \u00eatre au format AAAA-MM-JJ. Veuillez corriger cela avant de soumettre \u00e0 nouveau\");\n            return;\n        }\n        if (!isValidBirthdate(birthdateValue)) {\n            var birthdateYear = new Date(birthdateValue).getFullYear();\n            var currentYear = new Date().getFullYear();\n            if (birthdateYear < 1900) {\n                alert(\"L'ann\u00e9e de naissance \" + birthdateYear + \" semble incorrecte. Veuillez v\u00e9rifier votre date de naissance et r\u00e9essayer.\");\n            } else if (birthdateYear > currentYear) {\n                alert(\"La date de naissance ne peut pas \u00eatre dans le futur. Veuillez v\u00e9rifier votre date de naissance et r\u00e9essayer.\");\n            } else {\n                alert(\"La date de naissance semble invalide. Veuillez v\u00e9rifier que l'ann\u00e9e est correcte (devrait \u00eatre entre 1900 et \" + currentYear + \").\");\n            }\n            jQuery(\"#loadingDiv\").hide();\n            jQuery(\"#questionnaireForm\").show();\n            return;\n        }\n        if (!isValidDate(jQuery('#departureDate').val()) && jQuery('#departureDate').val() != \"\") {\n            alert(\"La date de d\u00e9part doit \u00eatre au format AAAA-MM-JJ. Veuillez corriger cela avant de soumettre \u00e0 nouveau\");\n            return;\n        }\n\n        \/\/validate allergiesOther field length (max 250 characters for Salesforce)\n        var allergiesOtherValue = jQuery(\"#allergiesOther\").val();\n        if (allergiesOtherValue && allergiesOtherValue.length > 250) {\n            alert(\"Le champ 'Allergies' est trop long (\" + allergiesOtherValue.length + \" caract\u00e8res). Veuillez le r\u00e9duire \u00e0 250 caract\u00e8res ou moins.\");\n            jQuery(\"#loadingDiv\").hide();\n            jQuery(\"#questionnaireForm\").show();\n            return;\n        }\n\n        \/\/validate cardioDiseaseOther field length (max 250 characters for Salesforce)\n        var cardioDiseaseOtherValue = jQuery(\"#cardioDiseaseOther\").val();\n        if (cardioDiseaseOtherValue && cardioDiseaseOtherValue.length > 250) {\n            alert(\"Le champ 'Autre maladie cardiaque' est trop long (\" + cardioDiseaseOtherValue.length + \" caract\u00e8res). Veuillez le r\u00e9duire \u00e0 250 caract\u00e8res ou moins.\");\n            jQuery(\"#loadingDiv\").hide();\n            jQuery(\"#questionnaireForm\").show();\n            return;\n        }\n\n        \/\/validate vaccineReceivingCountry field length (max 255 characters for Salesforce)\n        var vaccineReceivingCountryValue = jQuery(\"#radioVaccineCountry\").val();\n        if (vaccineReceivingCountryValue && vaccineReceivingCountryValue.length > 255) {\n            alert(\"Le champ 'Province\/pays de vaccination' est trop long (\" + vaccineReceivingCountryValue.length + \" caract\u00e8res). Veuillez le r\u00e9duire \u00e0 255 caract\u00e8res ou moins.\");\n            jQuery(\"#loadingDiv\").hide();\n            jQuery(\"#questionnaireForm\").show();\n            return;\n        }\n\n        \/\/validate departure date now too\n        if (jQuery(\"#countrySearch\").val() != \"\") {\n            console.log(\"there is a coutnry there\");\n            jQuery('.addCountry').click();\n        }\n        jQuery(\"#loadingDiv\").show();\n        jQuery(\"#questionnaireForm\").hide();\n        \/\/get the action-url of the form\n        var url = new URL(window.location.href);\n        var formType = url.searchParams.get(\"formType\");\n        var questionnaireId = url.searchParams.get(\"questionnaireId\");\n        var TBSymptoms = \"\";\n        var cardioDisease = \"\";\n        var respiratoryIllness = \"\";\n        var liverDisease = \"\";\n        var neurologicalDisorder = \"\";\n        var psychiatricDisorder = \"\";\n        var skinDisorder = \"\";\n        var immunoSuppressed = \"\";\n        var contactPopulation = \"\";\n        var adverseReactionToVaccine = \"\";\n        var travelPurpose = \"\";\n        var travelActivities = \"\";\n        var travelAccommodation = \"\";\n        var digestiveIllness = \"\";\n        var destinations = [];\n        var destinationCity = {};\n\n        \/\/ Sleep\n        var sleepSymptoms = \"\"\n\n        jQuery('.destination-section .repeatingSection table tbody tr').each(function () {\n            var idIndex = countryArray.indexOf(jQuery(this).find('.countrySearchtd').html())\n            destinationCity = {\n                \"id\": countryIds[idIndex],\n                \"country\": jQuery(this).find('.countrySearchtd').html(),\n                \"citiesToVisit\": jQuery(this).find('.citiesVisitedtd').html(),\n                \"daysToVisit\": jQuery(this).find('.daystd').html()\n            }\n            destinations.push(destinationCity);\n        });\n\n\n        if (!destinations.length && formType === \"travel\") {\n            console.log(\"no destinations added. Clicking\");\n            alert(\n                \"Il semble que vous n'ayez ajout\u00e9 aucune destination. Veuillez vous assurer d'ajouter au moins une destination \u00e0 votre liste\")\n            \/\/jQuery('.addCountry').click();\n            jQuery(\"#loadingDiv\").hide();\n            jQuery(\"#questionnaireForm\").show();\n            return;\n        }\n        jQuery('input[name=\"TBSymptoms\"]:checked').each(function () {\n            TBSymptoms = TBSymptoms + this.value + ';';\n        });\n        jQuery('input[name=\"cardioDisease\"]:checked').each(function () {\n            cardioDisease = cardioDisease + this.value + ';';\n        });\n        jQuery('input[name=\"respiratoryIllness\"]:checked').each(function () {\n            respiratoryIllness = respiratoryIllness + this.value + ';';\n        });\n        jQuery('input[name=\"liverDisease\"]:checked').each(function () {\n            liverDisease = liverDisease + this.value + ';';\n        });\n        jQuery('input[name=\"neurologicalDisorder\"]:checked').each(function () {\n            neurologicalDisorder = neurologicalDisorder + this.value + ';';\n        });\n        jQuery('input[name=\"psychiatricDisorder\"]:checked').each(function () {\n            psychiatricDisorder = psychiatricDisorder + this.value + ';';\n        });\n        jQuery('input[name=\"skinDisorder\"]:checked').each(function () {\n            skinDisorder = skinDisorder + this.value + ';';\n        });\n        jQuery('input[name=\"immunoSuppressed\"]:checked').each(function () {\n            immunoSuppressed = immunoSuppressed + this.value + ';';\n        });\n        jQuery('input[name=\"contactPopulation\"]:checked').each(function () {\n            contactPopulation = contactPopulation + this.value + ';';\n        });\n        jQuery('input[name=\"adverseReactionToVaccine\"]:checked').each(function () {\n            adverseReactionToVaccine = adverseReactionToVaccine + this.value + ';';\n        });\n        jQuery('input[name=\"travelPurpose\"]:checked').each(function () {\n            travelPurpose = travelPurpose + this.value + ';';\n        });\n        jQuery('input[name=\"travelActivities\"]:checked').each(function () {\n            travelActivities = travelActivities + this.value + ';';\n        });\n        jQuery('input[name=\"travelAccommodation\"]:checked').each(function () {\n            travelAccommodation = travelAccommodation + this.value + ';';\n        });\n        jQuery('input[name=\"digestiveIllness\"]:checked').each(function () {\n            digestiveIllness = digestiveIllness + this.value + ';';\n        });\n\n        \/\/ Sleep\n        jQuery('input[name=\"sleepSymptoms\"]:checked').each(function () {\n            sleepSymptoms = sleepSymptoms + this.value + ';';\n        });\n\n        var timeOfDay = '';\n        jQuery('input[name=\"timeOfDay\"]:checked').each(function () {\n            timeOfDay += this.value + ';';\n        });\n\n        \/**handle file upload section **\/\n        let justfileData;\n        let fileType;\n\n        async function getBase64(file) {\n            return new Promise((resolve, reject) => {\n                const reader = new FileReader();\n                reader.readAsDataURL(file);\n                reader.onload = () => resolve(reader.result);\n                reader.onerror = error => reject(error);\n            });\n        }\n\n        let fileUploadBody = {}\n        var file = document.querySelector('#immunizationRecordUpload').files[0];\n        if (file) {\n            let data = await getBase64(file);\n            let justFileData = data.substring(data.indexOf(\",\") + 1);\n            let uploadedFileType = data.substring(data.indexOf(\"\/\") + 1, data.indexOf(\";\")).trim();\n            \/\/ console.log(\"filedata: \",justFileData);\n            console.log(\"filetype: \", fileType);\n            fileUploadBody.fileType = uploadedFileType;\n            fileUploadBody.documentData = justFileData;\n        }\n        \/** end of file upload section **\/\n       \/\/ const selectedDoctorId = document.querySelector('input[name=\"doctorSelection\"]:checked')?.value || null;\n   \/\/ const selectedDentistId = document.querySelector('input[name=\"dentistSelection\"]:checked')?.value || null;\n  \n   var formData = {\n            \"questionnaireId\": questionnaireId,\n            \"websiteDomain\": window.location.hostname,\n            \"demographicInformation\": {\n                \"firstName\": jQuery(\"#firstName\").val(),\n                \"lastName\": jQuery(\"#lastName\").val(),\n                \"birthdate\": jQuery(\"#birthdate\").val(),\n                \"street\": jQuery(\"#street\").val(),\n                \"city\": jQuery(\"#city\").val(),\n                \"province\": jQuery(\"#province\").val(),\n                \"postalCode\": jQuery(\"#postalCode\").val(),\n                \"email\": jQuery(\"#email\").val(),\n                \"phone\": jQuery(\"#phone\").val(),\n                \"healthCardNumber\": jQuery(\"#healthCardNumber\").val(),\n                \"occupation\": jQuery(\"#occupation\").val(),\n                \"language\": jQuery(\"#language\").val()\n            },\n            \"pharmacyInformation\": {\n                \"pharmacyName\": jQuery(\"#pharmacyName\").val(),\n                \"pharmacyStreet\": jQuery(\"#pharmacyStreet\").val(),\n                \"pharmacyCity\": jQuery(\"#pharmacyCity\").val(),\n                \"pharmacyFax\": jQuery(\"#pharmacyFax\").val().replace(\/\\D\/g, '')\n            },\n            \"medicalInformation\": {\n                \"tbSymptoms\": TBSymptoms,\n                \"previousPositiveTBTest\": jQuery(\"#previousPositiveTBTest\").val(),\n                \"previousPositiveTBTestOther\": jQuery(\"#previousPositiveTBTestOther\").val(),\n                \"contactWithTB\": jQuery(\"#contactWithTB\").val(),\n                \"contactWithTBOther\": jQuery(\"#contactWithTBOther\").val(),\n                \"BCGVaccinated\": jQuery(\"#BCGVaccinated\").val(),\n                \"BCGVaccinatedOther\": jQuery(\"#BCGVaccinatedOther\").val(),\n                \"reasonForTBTest\": jQuery(\"#reasonForTBTest\").val(),\n\n                \"cardioDisease\": cardioDisease,\n                \"cardioDiseaseOther\": jQuery(\"#cardioDiseaseOther\").val(),\n                \"allergies\": jQuery('#allergies').val(),\n                \"allergiesOther\": jQuery(\"#allergiesOther\").val(),\n                \"respiratoryIllness\": respiratoryIllness,\n                \"respiratoryIllnessOther\": jQuery(\"#respiratoryIllnessOther\").val(),\n                \"digestiveIllness\": digestiveIllness,\n                \"digestiveIllnessOther\": jQuery(\"#digestiveIllnessOther\").val(),\n                \"liverDisease\": liverDisease,\n                \"liverDiseaseOther\": jQuery(\"#liverDiseaseOther\").val(),\n                \"kidneyIllness\": jQuery('input[name=radiokidney]:checked').val(),\n                \"kidneyIllnessOther\": jQuery(\"#kidneyIllnessOther\").val(),\n                \"cancer\": jQuery('input[name=\"radioCancer\"]:checked').val(),\n                \"cancerOther\": jQuery(\"#cancerOther\").val(),\n                \"neurologicalDisorder\": neurologicalDisorder,\n                \"neurologicalDisorderOther\": jQuery(\"#neurologicalDisorderOther\").val(),\n                \"psychiatricDisorder\": psychiatricDisorder,\n                \"psychiatricDisorderOther\": jQuery(\"#psychiatricDisorderOther\").val(),\n                \"skinDisorder\": skinDisorder,\n                \"skinDisorderOther\": jQuery(\"#skinDisorderOther\").val(),\n                \"immunoSuppressed\": immunoSuppressed,\n                \"immunoSuppressedOther\": jQuery('#immunoSuppressedOher').val(),\n                \"diabetes\": jQuery('input[name=\"radiodiabetes\"]:checked').val(),\n                \"diabetesOther\": jQuery(\"#diabetesOther\").val(),\n                \"chronicIllness\": jQuery(\"#chronicIllness\").val(),\n                \"maternity\": jQuery(\"#maternity\").val(),\n                \"medications\": jQuery(\"#medications\").val(),\n                \"receivedChildhoodVaccines\": jQuery('input[name=\"radioVaccine\"]:checked').val(),\n                \"vaccineReceivingCountry\": jQuery(\"#radioVaccineCountry\").val(),\n                \"contactPopulation\": contactPopulation,\n                \"adverseReactionToVaccine\": adverseReactionToVaccine,\n                \"adverseReactionToVaccineOther\": jQuery(\"#adverseReactionToVaccineOther\").val(),\n                \"smokeCigarettes\": jQuery('input[name=\"radioSmoke\"]:checked').val(),\n            },\n            \"lifeStyle\": {\n                \"tobacco\": {\n                    \"everSmoked\": jQuery('input[name=everSmoke]:checked').val(),\n                    \"stillSmoking\": jQuery('input[name=stillSmoking]:checked').val(),\n                    \"cigarettesPerDay\": jQuery('input[name=cigarettesPerDay]').val(),\n                    \"yearsSmoking\": jQuery('input[name=yearsSmoking]').val(),\n                    \"yearsStopped\": jQuery('input[name=yearsStopped]').val(),\n                },\n                \"alcohol\": {\n                    \"doDrink\": jQuery('input[name=alcohol]:checked').val(),\n                    \"timeOfDay\": timeOfDay,\n                    \"drinksPerWeek\": jQuery('input[name=drinksPerWeek]').val()\n                },\n                \"drugs\": {\n                    \"doUseDrugs\": jQuery('input[name=drugs]:checked').val(),\n                    \"drugType\": jQuery('input[name=drugType]').val()\n                },\n                \"coffee\": {\n                    \"cupsPerDay\": jQuery('#coffeeCupsPerDay').val()\n                }\n            },\n            \"referrerInformation\":{\n                    \"referringDoctorFirstName\": document.getElementById('doctorFirstName')?.value.trim(),\n                    \"referringDoctorLastName\": document.getElementById('doctorLastName')?.value.trim(),\n                    \"referringDoctorId\": selectedDoctorId,\n                    \"referringDentistFirstName\": document.getElementById('dentistFirstName')?.value.trim(),\n                    \"referringDentistLastName\": document.getElementById('dentistLastName')?.value.trim(),\n                    \"referringDentistId\": selectedDentistId,\n            },\n\n            \"newsletterSubscription\": formType === \"sleep\" ? jQuery('#newsletterSubscription').is(':checked') : null,\n            \"sleepScreening\": {\n                \"stopBangTotal\": getStopBangData(),\n                \"epworthScaleTotal\": getEpworthData(),\n                \"sleepSymptoms\": sleepSymptoms,\n                \"stopBang\": {\n                    \"snoreLoudly\": jQuery('div[name=\"first\"].choice.selectedBtn').text().trim(),\n                    \"feelTired\": jQuery('div[name=\"second\"].choice.selectedBtn').text().trim(),\n                    \"observedStopBreathing\": jQuery('div[name=\"third\"].choice.selectedBtn').text().trim(),\n                    \"highBloodPressure\": jQuery('div[name=\"fourth\"].choice.selectedBtn').text().trim(),\n                    \"bmi\": {\n                        \"weight\": jQuery('#bmi-weight').val(),\n                        \"weightUnit\": jQuery('#weightUnit').text(),\n                        \"height\": jQuery('#bmi-height').val(),\n                        \"heightUnit\": jQuery('#heightUnit').text(),\n                    },\n                    \"ageGroup\": jQuery('div[name=\"sixth\"].choice.selectedBtn').text().trim(),\n                    \"neckCircumference\": document.getElementById('neck-circumference').value,\n                    \"gender\": jQuery('div[name=\"eighth\"].choice.selectedBtn').text().trim(),\n                },\n                \"epworthScale\": {\n                    \"sittingReading\": jQuery('input[name=\"question1\"]:checked').val(),\n                    \"watchingTV\": jQuery('input[name=\"question2\"]:checked').val(),\n                    \"sittingInactive\": jQuery('input[name=\"question3\"]:checked').val(),\n                    \"lyingDownRest\": jQuery('input[name=\"question4\"]:checked').val(),\n                    \"talkingToSomeone\": jQuery('input[name=\"question5\"]:checked').val(),\n                    \"sittingQuietly\": jQuery('input[name=\"question6\"]:checked').val(),\n                    \"passengerInCar\": jQuery('input[name=\"question7\"]:checked').val(),\n                    \"stoppedInTraffic\": jQuery('input[name=\"question8\"]:checked').val(),\n                },\n            },\n\n            \"destinations\": destinations,\n            \"travelInformation\": {\n                \"departureDate\": jQuery(\"#departureDate\").val(),\n                \"travelPurpose\": travelPurpose,\n                \"travelActivities\": travelActivities,\n                \"travelActivitiesOther\": jQuery(\"#travelActivitiesOther\").val(),\n                \"travelAccommodation\": travelAccommodation,\n                \"travelAccommodationOther\": jQuery(\"#travelAccommodationOther\").val()\n            },\n            \"emergencyInformation\": {\n                \"emergencyContactName\": jQuery('#emergencyContactName').val(),\n                \"emergencyContactNumber\": jQuery('#emergencyContactNumber').val(),\n                \"guardianName\": jQuery('#guardianName').val()\n            },\n            \"fileUpload\": fileUploadBody\n        };      \n        \n        if (jQuery(\"#state\").val()) {\n            console.log(\"there is a state. Changing province val\")\n            formData.demographicInformation.province = jQuery(\"#state\").val();\n        }\n        if (jQuery(\"#zipCode\").val()) {\n            formData.demographicInformation.postalCode = jQuery(\"#zipCode\").val();\n        }\n        console.log('formData: ',formData);\n        jQuery.ajax({\n            type: \"POST\",\n            url: \"https:\/\/api.summittravelhealthdev.com\/v1\/questionnaire\/submitQuestionnaire\",\n            data: JSON.stringify(formData),\n            dataType: \"json\",\n        }).done(function (data) {\n            console.log('sent data: ',data);\n            \/**MAKE SURE YOU DON\"T COMENT THIS OUT BELOW ONLY FOR TESTING **\/\n            window.location.href = \"https:\/\/\"+window.location.hostname+\"\/fr\/questionnaire-complet\/\";\n        }).fail(function (data) {\n            console.log(\"Error from Api\", data);\n            jQuery(\"#loadingDiv\").hide();\n            jQuery(\"#questionnaireForm\").show();\n            alert(\"Il y a eu un probl\u00e8me lors de la soumission de votre questionnaire. Veuillez v\u00e9rifier que vous avez soumis tous les champs et que toutes les dates sont au format AAAA-MM-JJ. Si ce probl\u00e8me persiste, veuillez contacter l'\u00e9quipe de support de Summit \u00e0 support@\"+window.location.hostname);\n            console.log(\"Error from Api message\", data.message);\n\n        });\n\n\n    }\n\n    function customValidation() {\n        if (jQuery(\"#postalCode\").val().length !== 6) {\n            jQuery('.postal .error-message').remove();\n            jQuery('.postal').append('<div class=\"error-message\">Le code postal doit comporter 6 chiffres<\/div>');\n            jQuery('.postal .form-control').addClass(\"is-invalid\");\n            jQuery('.postal .form-control').removeClass(\"is-valid\");\n            return false;\n        } else if (jQuery(\"#postalCode\").val().length === 6) {\n            jQuery('.postal .error-message').remove();\n            jQuery('.postal .form-control').addClass(\"is-valid\");\n            jQuery('.postal .form-control').removeClass(\"is-invalid\");\n            return true;\n\n        }\n\n    }\n\n    function autocomplete(inp, arr) {\n        \/*the autocomplete function takes two arguments,\n        the text field element and an array of possible autocompleted values:*\/\n        var currentFocus;\n        \/*execute a function when someone writes in the text field:*\/\n        inp.addEventListener(\"input\", function (e) {\n            var a, b, i, val = this.value;\n            \/*close any already open lists of autocompleted values*\/\n            closeAllLists();\n            if (!val) {\n                return false;\n            }\n            currentFocus = -1;\n            \/*create a DIV element that will contain the items (values):*\/\n            a = document.createElement(\"DIV\");\n            a.setAttribute(\"id\", this.id + \"autocomplete-list\");\n            a.setAttribute(\"class\", \"autocomplete-items\");\n            \/*append the DIV element as a child of the autocomplete container:*\/\n            this.parentNode.appendChild(a);\n            \/*for each item in the array...*\/\n            for (i = 0; i < arr.length; i++) {\n                \/*check if the item starts with the same letters as the text field value:*\/\n                if (arr[i].substr(0, val.length).toUpperCase() == val.toUpperCase()) {\n                    \/*create a DIV element for each matching element:*\/\n                    b = document.createElement(\"DIV\");\n                    \/*make the matching letters bold:*\/\n                    b.innerHTML = \"<strong>\" + arr[i].substr(0, val.length) + \"<\/strong>\";\n                    b.innerHTML += arr[i].substr(val.length);\n                    \/*insert a input field that will hold the current array item's value:*\/\n                    b.innerHTML += \"<input type='hidden' value='\" + arr[i] + \"'>\";\n                    \/*execute a function when someone clicks on the item value (DIV element):*\/\n                    b.addEventListener(\"click\", function (e) {\n                        \/*insert the value for the autocomplete text field:*\/\n                        inp.value = this.getElementsByTagName(\"input\")[0].value;\n                        \/*close the list of autocompleted values,\n                        (or any other open lists of autocompleted values:*\/\n                        closeAllLists();\n                    });\n                    a.appendChild(b);\n                }\n            }\n        });\n        \/*execute a function presses a key on the keyboard:*\/\n        inp.addEventListener(\"keydown\", function (e) {\n            var x = document.getElementById(this.id + \"autocomplete-list\");\n            if (x) x = x.getElementsByTagName(\"div\");\n            if (e.keyCode == 40) {\n                \/*If the arrow DOWN key is pressed,\n                increase the currentFocus variable:*\/\n                currentFocus++;\n                \/*and and make the current item more visible:*\/\n                addActive(x);\n            } else if (e.keyCode == 38) { \/\/up\n                \/*If the arrow UP key is pressed,\n                decrease the currentFocus variable:*\/\n                currentFocus--;\n                \/*and and make the current item more visible:*\/\n                addActive(x);\n            } else if (e.keyCode == 13) {\n                \/*If the ENTER key is pressed, prevent the form from being submitted,*\/\n                e.preventDefault();\n                if (currentFocus > -1) {\n                    \/*and simulate a click on the \"active\" item:*\/\n                    if (x) x[currentFocus].click();\n                }\n            }\n        });\n\n        function addActive(x) {\n            \/*a function to classify an item as \"active\":*\/\n            if (!x) return false;\n            \/*start by removing the \"active\" class on all items:*\/\n            removeActive(x);\n            if (currentFocus >= x.length) currentFocus = 0;\n            if (currentFocus < 0) currentFocus = (x.length - 1);\n            \/*add class \"autocomplete-active\":*\/\n            x[currentFocus].classList.add(\"autocomplete-active\");\n        }\n\n        function removeActive(x) {\n            \/*a function to remove the \"active\" class from all autocomplete items:*\/\n            for (var i = 0; i < x.length; i++) {\n                x[i].classList.remove(\"autocomplete-active\");\n            }\n        }\n\n        function closeAllLists(elmnt) {\n            \/*close all autocomplete lists in the document,\n            except the one passed as an argument:*\/\n            var x = document.getElementsByClassName(\"autocomplete-items\");\n            for (var i = 0; i < x.length; i++) {\n                if (elmnt != x[i] && elmnt != inp) {\n                    x[i].parentNode.removeChild(x[i]);\n                }\n            }\n        }\n\n        \/*execute a function when someone clicks in the document:*\/\n        document.addEventListener(\"click\", function (e) {\n            closeAllLists(e.target);\n        });\n    }\n\n    function calculateAge(birthdate) {\n        const today = new Date();\n        const birthDate = new Date(birthdate);\n        let age = today.getFullYear() - birthDate.getFullYear();\n        const m = today.getMonth() - birthDate.getMonth();\n        if (m < 0 || (m === 0 && today.getDate() < birthDate.getDate())) {\n            age--;\n        }\n        return age;\n    }\n \n    const sections = [\n        { selector: '.main-info',       label: 'Information d\u00e9mographique' },\n        { selector: '.medical-section', label: 'Informations m\u00e9dicales' },\n        { selector: '.lifestyle-section', label: 'Informations sur le mode de vie' },\n        { selector: '.sleep-screening-section', label: 'D\u00e9pistage du sommeil' },\n        { selector: '.destination-section', label: 'Informations sur la destination' },\n        { selector: '.trip-section',    label: 'Information sur le voyage' },\n        { selector: '.emergency-section', label: 'Personne \u00e0 contacter en cas d\\'urgence' }\n    ];\n\n    \/\/ Valider les groupes de cases \u00e0 cocher comme une seule exigence\n    function validateCheckboxGroups() {\n        jQuery('.question.required:visible').each(function () {\n            const $group = jQuery(this);\n            const $boxes = $group.find('input[type=\"checkbox\"]:visible');\n            if ($boxes.length === 0) return; \/\/ Pas de cases \u00e0 cocher dans cette question\n\n            const anyChecked = $boxes.is(':checked');\n            \/\/ Utiliser la validation HTML5 en ne rendant obligatoire que la premi\u00e8re case si aucune n'est coch\u00e9e\n            $boxes.prop('required', false);\n            if (!anyChecked) {\n                $boxes.first().prop('required', true);\n                $group.addClass('has-checkbox-error');\n                if ($group.find('.error-message.group').length === 0) {\n                    $group.append('<div class=\"error-message group\">Veuillez s\u00e9lectionner au moins une option ou cochez \u00ab Aucun \u00bb s\\'il y a lieu.<\/div>');\n                }\n            } else {\n                $group.removeClass('has-checkbox-error');\n                $group.find('.error-message.group').remove();\n            }\n        });\n    }\n\n    \/\/ Revalider lorsqu'une case change\n    jQuery(document).on('change', '.question.required input[type=\"checkbox\"]', function(){\n        validateCheckboxGroups();\n    });\n\n    function getInvalidSections() {\n        \/\/ Normaliser d'abord les exigences des groupes de cases \u00e0 cocher\n        validateCheckboxGroups();\n\n        let invalidSections = [];\n        for (let s of sections) {\n            let sectionIsInvalid = false;\n            console.log(`[DEBUG] Checking section: ${s.label} (${s.selector})`);\n\n            \/\/ V\u00e9rifier les champs requis classiques (textes, selects, radios)\n            jQuery(s.selector).find('.form-control[required]:visible, input[type=\"radio\"][required]:visible').each(function(){\n                if (!this.checkValidity()) {\n                    console.log(`[DEBUG] Invalid field found in ${s.label}:`, this.id || this.name, this.type);\n                    sectionIsInvalid = true;\n                    return false; \/\/ break\n                }\n            });\n            if (sectionIsInvalid) { \n                console.log(`[DEBUG] Section ${s.label} is invalid due to form controls`);\n                invalidSections.push(s.label); \n                continue; \n            }\n\n            \/\/ V\u00e9rifier chaque groupe de cases \u00e0 cocher requis\n            jQuery(s.selector).find('.question.required:visible').each(function(){\n                const $boxes = jQuery(this).find('input[type=\"checkbox\"]:visible');\n                if ($boxes.length > 0 && !$boxes.is(':checked')) {\n                    console.log(`[DEBUG] Invalid checkbox group found in ${s.label}:`, this);\n                    sectionIsInvalid = true;\n                    return false; \/\/ break\n                }\n            });\n\n            if (sectionIsInvalid) {\n                console.log(`[DEBUG] Section ${s.label} is invalid due to checkbox groups`);\n                invalidSections.push(s.label);\n            } else {\n                console.log(`[DEBUG] Section ${s.label} is valid`);\n            }\n        }\n        console.log(`[DEBUG] Invalid sections:`, invalidSections);\n        return invalidSections;\n    }\n\n    jQuery(document).ready(function () {\n        jQuery('.sib_signup_form').remove()\n        var url = new URL(window.location.href);\n        var formType = \"\";\n        formType = url.searchParams.get(\"formType\");\n        var clientName = url.searchParams.get(\"clientName\");\n        \/\/ console.log(\"the client name is: \" + clientName);\n        var questionnaireId = url.searchParams.get(\"questionnaireId\");\n        let questionnaireURLFetch = \"https:\/\/api.summittravelhealthdev.com\/v1\/questionnaire\/\" +\n            questionnaireId;\n        jQuery('#continueQuestionnaireButton').hide()\n        \/\/birthdate datepicker\n        jQuery('.birthdate-date-picker').datepicker({\n            format: 'yyyy-mm-dd',\n            todayHighlight: true,\n            autoclose: true,\n        }).on('change', function () {\n            console.log(\"birthdate change function\")\n            jQuery('.datepicker').hide();\n            if (!isValidDate(jQuery('#birthdate').val()) && jQuery('#birthdate').val() != \"\") {\n                console.log(\"date is not valid\");\n                \/\/jQuery('.birthdate .error-message').remove();\n                \/**\n                 jQuery('.birthdate').append(\n                 '<div class=\"error-message\">Date format must be formatted YYYY-MM-DD<\/div>');\n                 jQuery('.birthdate .form-control').addClass(\"is-invalid\");\n                 jQuery('.birthdate .form-control').removeClass(\"is-valid\");\n                 console.log(\"marked invalid\");\n                 **\/\n            } else {\n                jQuery('.birthdate .error-message').remove();\n                jQuery('.birthdate .form-control').addClass(\"is-valid\");\n                jQuery('.birthdate .form-control').removeClass(\"is-invalid\");\n            }\n        });\n\n        jQuery('div[name=\"sixth\"]').css('pointer-events', 'none');\n\n        jQuery('#birthdate').on('change', function () {\n            const birthdateValue = jQuery(this).val();\n            if (birthdateValue) {\n                const age = calculateAge(birthdateValue);\n                if (age > 50) {\n                    onAnswerChose('sixth', 5, 1); \n                } else {\n                    onAnswerChose('sixth', 5, 0); \n                }\n            }\n        });\n\n        \/\/\/departure date picker\n        jQuery('.depart-date-picker').datepicker({\n            format: 'yyyy-mm-dd',\n            todayHighlight: true,\n            autoclose: true,\n        }).on('change', function () {\n            console.log(\"departure change function\")\n            jQuery('.datepicker').hide();\n            if (!isValidDate(jQuery('#departureDate').val()) && jQuery('#departureDate').val() != \"\") {\n                console.log(\"date is not valid\");\n                \/\/jQuery('.birthdate .error-message').remove();\n                \/**\n                 jQuery('.departureDate').append(\n                 '<div class=\"error-message\">Date format must be YYYY-MM-DD<\/div>');\n                 jQuery('.departureDate .form-control').addClass(\"is-invalid\");\n                 jQuery('.departureDate .form-control').removeClass(\"is-valid\");\n                 console.log(\"marked invalid\");\n                 **\/\n            } else {\n                jQuery('.departureDate .error-message').remove();\n                jQuery('.departureDate .form-control').addClass(\"is-valid\");\n                jQuery('.departureDate .form-control').removeClass(\"is-invalid\");\n            }\n\n        });\n\n        \/\/sisnett testing this\n        function isValidDate(dateString) {\n            var regEx = \/^\\d{4}-\\d{2}-\\d{2}$\/;\n            if (!dateString.match(regEx)) return false; \/\/ Invalid format\n            var d = new Date(dateString);\n            var dNum = d.getTime();\n            if (!dNum && dNum !== 0) return false; \/\/ NaN value, Invalid date\n            return d.toISOString().slice(0, 10) === dateString;\n        }\n\n        function isValidBirthdate(dateString) {\n            if (!isValidDate(dateString)) return false;\n            var d = new Date(dateString);\n            var today = new Date();\n            var year = d.getFullYear();\n            var currentYear = today.getFullYear();\n            var minYear = currentYear - 150; \/\/ Maximum age of 150 years\n            \n            \/\/ Check if date is in the future\n            if (d > today) return false;\n            \n            \/\/ Check if year is reasonable (not before 1900 and not more than 150 years ago)\n            if (year < 1900 || year < minYear) return false;\n            \n            return true;\n        }\n\n        jQuery(\"#birthdate\").focus(function () {\n            console.log('in birthdate');\n            jQuery('.birthdate .error-message').remove();\n        }).blur(function () {\n            console.log(\"date picker is\", jQuery('#birthdate').val())\n            var birthdateValue = jQuery('#birthdate').val();\n            if (birthdateValue != \"\") {\n                if (!isValidDate(birthdateValue)) {\n                    console.log(\"date is not valid\");\n                    jQuery('.birthdate .error-message').remove();\n                    jQuery('.birthdate').append(\n                        '<div class=\"error-message\">Le format de date doit \u00eatre AAAA-MM-JJ<\/div>');\n                    jQuery('.birthdate .form-control').addClass(\"is-invalid\");\n                    jQuery('.birthdate .form-control').removeClass(\"is-valid\");\n                    console.log(\"marked invalid\");\n                } else if (!isValidBirthdate(birthdateValue)) {\n                    console.log(\"date is not a valid birthdate\");\n                    jQuery('.birthdate .error-message').remove();\n                    var birthdateYear = new Date(birthdateValue).getFullYear();\n                    var currentYear = new Date().getFullYear();\n                    var errorMsg = \"La date de naissance semble invalide. \";\n                    if (birthdateYear < 1900) {\n                        errorMsg = \"L'ann\u00e9e de naissance \" + birthdateYear + \" semble incorrecte. Veuillez v\u00e9rifier votre date de naissance.\";\n                    } else if (birthdateYear > currentYear) {\n                        errorMsg = \"La date de naissance ne peut pas \u00eatre dans le futur. Veuillez v\u00e9rifier votre date de naissance.\";\n                    } else {\n                        errorMsg = \"La date de naissance semble invalide. Veuillez v\u00e9rifier que l'ann\u00e9e est correcte (devrait \u00eatre entre 1900 et \" + currentYear + \").\";\n                    }\n                    jQuery('.birthdate').append('<div class=\"error-message\">' + errorMsg + '<\/div>');\n                    jQuery('.birthdate .form-control').addClass(\"is-invalid\");\n                    jQuery('.birthdate .form-control').removeClass(\"is-valid\");\n                    console.log(\"marked invalid\");\n                } else {\n                    jQuery('.birthdate .error-message').remove();\n                    jQuery('.birthdate .form-control').addClass(\"is-valid\");\n                    jQuery('.birthdate .form-control').removeClass(\"is-invalid\");\n                }\n            }\n            console.log(\"focus out detected, hiding\");\n            \/\/ jQuery('.datepicker').datepicker('update');\n            \/\/jQuery('.datepicker').hide();\n        });\n        \n        \/\/newly added for departure date\n        jQuery(\"#departureDate\").focus(function () {\n            console.log('in departure date');\n            jQuery('.departureDate .error-message').remove();\n        }).blur(function () {\n            console.log(\"departure date picker is\", jQuery('#departureDate').val())\n            if (!isValidDate(jQuery('#departureDate').val()) && jQuery('#departureDate').val() != \"\") {\n                console.log(\"date is not valid\");\n                \/\/jQuery('.birthdate .error-message').remove();\n                jQuery('.departureDate').append(\n                    '<div class=\"error-message\">Date format must be YYYY-MM-DD<\/div>');\n                jQuery('.departureDate .form-control').addClass(\"is-invalid\");\n                jQuery('.departureDate .form-control').removeClass(\"is-valid\");\n                console.log(\"marked invalid\");\n            } else {\n                jQuery('.departureDate .error-message').remove();\n                jQuery('.departureDate .form-control').addClass(\"is-valid\");\n                jQuery('.departureDate .form-control').removeClass(\"is-invalid\");\n            }\n            console.log(\"focus out detected, hiding\");\n            \/\/ jQuery('.datepicker').datepicker('update');\n            \/\/jQuery('.datepicker').hide();\n        });\n        \/\/end of sisnett\n\n        jQuery.fn.datepicker.defaults.format = \"yyyy-mm-dd\";\n        jQuery.ajax({\n            url: questionnaireURLFetch,\n            method: 'GET',\n            dataType: 'json',\n            success: function (data) {\n                console.log(\"returned the following info from questionnaire: \", data);\n                \/\/jQuery(\"#continueQuestionnaireContainer\").hide();\n                if (!questionnaireId) {\n                    jQuery(\"#continueQuestionnaireText\").text(\n                        \"Il y a un probl\u00e8me, aucun ID de questionnaire valide n'a \u00e9t\u00e9 fourni\");\n                    jQuery(\"#continueQuestionnaireContainer\").show();\n                    jQuery(\"#questionnaireForm\").hide();\n                    jQuery('#continueQuestionnaireButton').hide()\n                }\n                if (data.datecompleted) {\n                    let formattedDate = data.datecompleted.substr(0, 10);\n                    jQuery(\"#continueQuestionnaireContainer\").show();\n                    jQuery(\"#questionnaireForm\").hide();\n                    jQuery(\"#continueQuestionnaireText\").text(\n                        \"Il semble que ce questionnaire ait \u00e9t\u00e9 soumis le \" +\n                        formattedDate + \" par \" + data.email +\n                        \". Veuillez confirmer si vous souhaitez continuer et refaire le questionnaire.\"\n                    );\n                    jQuery('#continueQuestionnaireButton').show();\n                    jQuery('#confirmNoChangesDiv').hide();\n                } else if (data.type == \"Booster\") {\n                    jQuery(\"#questionnaireForm\").hide();\n                    jQuery('#confirmNoChangesDiv').show();\n                }\n                jQuery(\"#firstName\").val(data.firstName)\n                jQuery(\"#lastName\").val(data.lastName)\n\n            },\n            error: function (data) {\n                console.log(\"error fetching questionnaire\", data);\n                jQuery(\"#continueQuestionnaireText\").text(\n                    \"Il y a un probl\u00e8me, aucun ID de questionnaire valide n'a \u00e9t\u00e9 fourni\");\n                jQuery(\"#continueQuestionnaireContainer\").show();\n                jQuery(\"#questionnaireForm\").hide();\n                jQuery('#continueQuestionnaireButton').hide()\n            }\n        });\n\n        \/\/do the work for the state and provinces\n        jQuery('#country USA:selected').hide();\n\n        jQuery('select[name=\"country\"]').change(function () {\n\n            if (jQuery(this).val() != \"Canada\") {\n                \/\/hide show divs\n                jQuery('#provinceDiv').hide();\n                jQuery('#stateDiv').show();\n                jQuery('#postalCodeDiv').hide();\n                jQuery('#zipCodeDiv').show();\n                \/\/set required .removeAttr('required'\n                jQuery('#province').removeAttr('required');\n                jQuery('#postalCode').removeAttr('required');\n                \/\/ alert(\"call the do something function on option USA\");\n            }\n        })\n\n        jQuery('#stateDiv').click(function () {\n            jQuery(\"#continueQuestionnaireContainer\").hide();\n            jQuery(\"#questionnaireForm\").show();\n            jQuery(\"#confirmNoChangesDiv\").hide();\n        });\n        \/\/end of the state and province stuff\n\n        jQuery('.continueQuestionnaireButton').click(function () {\n            jQuery(\"#continueQuestionnaireContainer\").hide();\n            jQuery(\"#questionnaireForm\").show();\n            jQuery(\"#confirmNoChangesDiv\").hide();\n        });\n\n        jQuery('#confirmNoChangesButton').click(function () {\n            if (!jQuery(\"#confirmNoChangeCheckbox\").is(':checked')) {\n                alert(\"Vous devez cocher la case pour confirmer\");\n                return\n            }\n            jQuery(\"#confirmNoChangesDiv\").hide();\n            jQuery(\"#loadingDiv\").show();\n            var url = new URL(window.location.href);\n            var questionnaireId = url.searchParams.get(\"questionnaireId\");\n            let formData = {\n                \"questionnaireId\": questionnaireId\n            }\n            console.log(\"confirming no changes\", formData);\n            jQuery.ajax({\n                type: \"POST\",\n                url: \"https:\/\/api.summittravelhealthdev.com\/v1\/questionnaire\/submitNoChangesQuestionnaire\",\n                data: JSON.stringify(formData),\n                dataType: \"json\",\n            }).done(function (data) {\n                console.log(data);\n                \/\/ console.log(\"success\");\n                window.location.href = \"https:\/\/\"+window.location.hostname+\"\/fr\/questionnaire-complet\/\";\n            }).fail(function (data) {\n                console.log(\"Error from Api\", data);\n            });\n        });\n        var countrySearch = document.getElementById('countrySearch') \/\/jQuery('#countrySearch').val();\n        jQuery.ajax({\n            url: 'https:\/\/api.summittravelhealthdev.com\/v1\/questionnaire\/countries',\n            method: 'GET',\n            dataType: 'json',\n            success: function (data) {\n                for (var i = 0; i < data.countries.length; i++) {\n                    countryArray[i] = data.countries[i][\"CountryNameEN\"];\n                    countryIds[i] = data.countries[i][\"Id\"];\n                }\n                \/\/ console.log(countryArray);\n                autocomplete(countrySearch, countryArray);\n            }\n        });\n        \/**Client specific section for different requirements **\/\n        if (clientName === \"paladin\") {\n            console.log(\"the client is paladin, show the approval checkbox\");\n            jQuery(\"#paladinBullet\").show();\n            jQuery(\"#paladinCheckbox\").prop('required', true);\n\n        }\n\n        function disableItemsExceptSLeep() {\n            \/\/ Setup initial hide and show\n            jQuery(\"#occupation\").parent(\"div\").hide();\n            jQuery(\"#occupation\").prop('required', false);\n\n            \/\/ Hide lifestyle-section\n            jQuery('.lifestyle-section').hide().find('input, select, textarea').prop('required', false);\n            jQuery('.lifestyle-section').next('hr').hide();\n\n            \/\/ Hide sleep-screening-section\n            jQuery('.sleep-screening-section').hide().find('input, select, textarea').prop('required', false);\n            jQuery('.sleep-screening-section').next('hr').hide();\n\n            \/\/ Hide sleep-screening-section\n            jQuery('.only-sleep-question').hide().find('input, select, textarea').prop('required', false);\n            jQuery('.only-sleep-question').next('hr').hide();\n\n\n            jQuery('.sleep-section-terms').hide();\n\n            jQuery('.referrer-section').hide();\n            jQuery('.referrer-section').next('hr').hide();\n        }\n\n        \/\/Validation Functions\n        if (formType === \"travel\") {\n            jQuery(\".pharmacy-section\").show();\n            jQuery(\"#departureDate\").prop('required', true);\n            jQuery(\"#countrySearch\").prop('required', true);\n            jQuery(\"#citiesVisited\").prop('required', true);\n            jQuery(\"#days\").prop('required', true);\n            jQuery('.question.trip-info').addClass('required');\n            jQuery(\".travel-question\").show();\n            jQuery(\".tb-question\").hide();\n            jQuery(\".tb-question\").prop('required', false);\n\n            disableItemsExceptSLeep();\n\n        } else if (formType === \"COVID\") {\n            jQuery(\"#departureDate\").prop('required', false);\n            jQuery(\"#countrySearch\").prop('required', false);\n            jQuery(\"#citiesVisited\").prop('required', false);\n            jQuery(\"#days\").prop('required', false);\n            jQuery(\"#medications\").prop('required', false);\n            jQuery(\"#chronicIllness\").prop('required', false);\n            jQuery('.question.trip-info.required input[type=checkbox]').prop('required', false);\n            jQuery(\".medical-section .question.required .form-check input[type=checkbox]\").prop('required',\n                false);\n            jQuery(\".medical-section .question.required .form-check input[type=radio]\").prop('required',\n                false);\n            jQuery(\".medical-section .question.required\").removeClass(\"required\");\n            jQuery(\".tb-question\").prop('required', false);\n            \/\/hide the sections\n            jQuery(\".destination-section\").hide();\n            jQuery(\".trip-section\").hide();\n            jQuery(\".medical-section\").hide();\n            jQuery(\"#covidBullet\").show();\n\n            disableItemsExceptSLeep();\n\n        } else if (formType === \"TB\") {\n            jQuery(\"#departureDate\").prop('required', false);\n            jQuery(\"#countrySearch\").prop('required', false);\n            jQuery(\"#citiesVisited\").prop('required', false);\n            jQuery(\"#days\").prop('required', false);\n            jQuery(\"#chronicIllness\").prop('required', false);\n            jQuery('.question.trip-info.required input[type=checkbox]').prop('required', false);\n            jQuery(\".medical-section .question.required .form-check input[type=checkbox]\").prop('required',\n                false);\n            jQuery(\".medical-section .question.required .form-check input[type=radio]\").prop('required',\n                false);\n            jQuery(\".medical-section .question.required\").removeClass(\"required\");\n            jQuery(\"#medications\").prop('required', true);\n            jQuery(\"#reasonForTBTest\").prop('required', true);\n            jQuery(\"#previousPositiveTBTest\").prop('required', true);\n\n            \/\/hide the sections\n            jQuery(\".destination-section\").hide();\n            jQuery(\".trip-section\").hide();\n            jQuery(\"#covidBullet\").hide();\n            jQuery(\".travel-question\").hide();\n            jQuery(\".tb-question\").show();\n\n            disableItemsExceptSLeep();\n\n        } else if (formType == \"sleep\") {\n            jQuery(document).ready(function () {\n\n                \/\/ Modify Terms\n                jQuery('.not-sleep-section-terms').hide();\n                jQuery('#agreementCheckbox').next('label').text('J\\'accepte les termes et conditions ci-dessus');\n\n                \/\/ Neck circumference\n                jQuery(\"#neck-circumference\").prop(\"required\", true);\n\n                \/\/ Tobacco Section: Show \"Are you still smoking?\" only if \"Have you ever smoked?\" is \"Yes\"\n                jQuery('.smoke-ever').on('change', function () {\n                    if (jQuery(this).val() === 'yes') {\n                        jQuery('.still-smoking-question').show();\n                    } else {\n                        jQuery('.still-smoking-question').hide();\n                        jQuery('.tobacco-details').hide().find('input').prop('required', false);\n                    }\n                });\n\n                \/\/ Show tobacco details if either question is answered \"Yes\"\n                jQuery('.smoke-ever, .smoke-still').on('change', function () {\n                    const everSmokeYes = jQuery('input[name=\"everSmoke\"]:checked').val() === 'yes';\n                    const stillSmokeYes = jQuery('input[name=\"stillSmoking\"]:checked').val() === 'yes';\n\n                    if (everSmokeYes || stillSmokeYes) {\n                        jQuery('.tobacco-details').show().find('input').prop('required', true);\n                    } else {\n                        jQuery('.tobacco-details').hide().find('input').prop('required', false);\n                    }\n                });\n\n                \/\/ Alcohol Section\n                jQuery('.alcohol-answer').on('change', function () {\n                    if (jQuery(this).val() === 'yes') {\n                        jQuery('.alcohol-details').show().find('input').prop('required', true);\n                        jQuery('.question.sleep-question').addClass('required');\n                    } else {\n                        jQuery('.alcohol-details').hide().find('input').prop('required', false);\n                        jQuery('.question.sleep-question').removeClass('required');\n                    }\n                });\n\n                \/\/ Drugs Section\n                jQuery('.drugs-answer').on('change', function () {\n                    if (jQuery(this).val() === 'yes') {\n                        jQuery('.drugs-details').show().find('input').prop('required', true);\n                    } else {\n                        jQuery('.drugs-details').hide().find('input').prop('required', false);\n                    }\n                });\n            });\n\n\n            jQuery(\"#healthCardNumber\").prop('required', true);\n            jQuery(\"#healthCardNumber\").prev(\"label\").append('<span class=\"astrisc\">*<\/span>');\n            jQuery(\"#healthCardNumber\").after('<div class=\"invalid-feedback\">Le num\u00e9ro de carte de sant\u00e9 est un champ obligatoire<\/div>');\n\n            jQuery(\"#occupation\").parent(\"div\").show();\n            jQuery(\"#occupation\").prop('required', true);\n            jQuery(\"#occupation\").prev(\"label\").append('<span class=\"astrisc\">*<\/span>');\n            jQuery(\"#occupation\").after('<div class=\"invalid-feedback\">La profession est un champ obligatoire<\/div>');\n\n            jQuery('.medical-section .question, .medical-section .question-group').not('.sleep-question').removeClass('required').hide().find('input, select, textarea').prop('required', false);\n            \/\/jQuery('.medical-section > div').not('.sleep-question').removeClass('required').hide().find('input, select, textarea').prop('required', false);\n\n            \/\/destination-section\n            jQuery('.destination-section').hide().find('input, select, textarea').prop('required', false);\n            jQuery('.destination-section').next('hr').hide();\n\n            \/\/trip-section\n            jQuery('.trip-section').hide().find('input, select, textarea').prop('required', false);\n            jQuery('.trip-section').next('hr').hide();\n\n            jQuery('.referrer-section').show();\n            jQuery('.referrer-section').next('hr').show();\n\n            \/\/sleep section \n            jQuery('.sleep-screening-section').show();\n            jQuery('.sleep-screening-section')\n                .find('input, select, textarea')\n                .prop('required', true);\n\n            jQuery('.only-sleep-question').show();\n            jQuery('.only-sleep-question')\n                .find('input, select, textarea')\n                .prop('required', true);\n\n            \/\/adding information from Francois email\n             jQuery('.emergency-section').hide();\n             jQuery(\"#emergencyContactName\").prop('required', false);\n             jQuery(\"#emergencyContactNumber\").prop('required', false);\n            \/\/end of information from Francois email\n\n        } else {\n            jQuery(\"#departureDate\").prop('required', false);\n            jQuery(\"#countrySearch\").prop('required', false);\n            jQuery(\"#citiesVisited\").prop('required', false);\n            jQuery(\"#days\").prop('required', false);\n            jQuery('.question.trip-info.required input[type=checkbox]').prop('required', false);\n            \/\/hide the sections\n            jQuery(\".destination-section\").hide();\n            jQuery(\".trip-section\").hide();\n            jQuery(\".tb-question\").hide();\n\n            disableItemsExceptSLeep();\n        }\n        jQuery('#submitBtnId').click(function () {\n            if (jQuery(\"table tr\").length > 0 || formType !== \"travel\") {\n                jQuery(\"#countrySearch\").prop('required', false);\n                jQuery(\"#citiesVisited\").prop('required', false);\n                jQuery(\"#days\").prop('required', false);\n            } else {\n                jQuery(\"#countrySearch\").prop('required', true);\n                jQuery(\"#citiesVisited\").prop('required', true);\n                jQuery(\"#days\").prop('required', true);\n            }\n        });\n        \/\/end validation functions\n\n        \/\/Hide other field on selection\n        jQuery('input#Other').each(function () {\n\n            jQuery('input#Other').on('click', function () {\n                if (jQuery(this).prop('checked')) {\n                    jQuery(this).parents('.question').find('.other-section').css('display',\n                        'block');\n                } else {\n                    jQuery(this).parents('.question').find('.other-section').css('display',\n                        'none');\n                }\n            });\n        });\n        jQuery('input#radioOther').each(function () {\n\n            jQuery('input#radioOther').on('click', function () {\n                if (jQuery(this).prop('checked') && jQuery(this).val() == \"true\") {\n                    jQuery(this).parents('.question').find('.other-section').css('display',\n                        'block');\n                } else if (jQuery(this).prop('checked') && jQuery(this).val() == \"false\") {\n                    jQuery(this).parents('.question').find('.other-section').css('display',\n                        'none');\n                }\n            });\n        });\n        jQuery(\"select#allergies\").change(function () {\n            if (jQuery('#allergies').val() == \"Yes\") {\n                jQuery(this).parent().find(\".other-section\").css(\"display\", \"block\");\n            } else {\n                jQuery(this).parent().find(\".other-section\").css(\"display\", \"none\");\n            }\n        });\n\n        \/\/ Character count and validation for allergiesOther field\n        function updateAllergiesCharCount() {\n            var value = jQuery(\"#allergiesOther\").val() || \"\";\n            var length = value.length;\n            var maxLength = 250;\n            var charCountEl = jQuery(\"#allergiesOtherCharCount\");\n            var errorEl = jQuery(\"#allergiesOtherError\");\n            \n            charCountEl.text(length + \" \/ \" + maxLength + \" caract\u00e8res\");\n            \n            if (length > maxLength) {\n                charCountEl.css(\"color\", \"red\");\n                charCountEl.css(\"font-weight\", \"bold\");\n                errorEl.text(\"Ce champ d\u00e9passe la longueur maximale de \" + maxLength + \" caract\u00e8res. Veuillez raccourcir votre texte.\");\n                errorEl.show();\n                jQuery(\"#allergiesOther\").addClass(\"is-invalid\");\n            } else if (length > maxLength * 0.9) {\n                charCountEl.css(\"color\", \"orange\");\n                charCountEl.css(\"font-weight\", \"normal\");\n                errorEl.hide();\n                jQuery(\"#allergiesOther\").removeClass(\"is-invalid\");\n            } else {\n                charCountEl.css(\"color\", \"\");\n                charCountEl.css(\"font-weight\", \"normal\");\n                errorEl.hide();\n                jQuery(\"#allergiesOther\").removeClass(\"is-invalid\");\n            }\n        }\n        \n        jQuery(\"#allergiesOther\").on(\"input keyup paste\", function() {\n            updateAllergiesCharCount();\n        });\n        \n        \/\/ Initialize character count on page load\n        updateAllergiesCharCount();\n\n        \/\/ Character count and validation for cardioDiseaseOther field\n        function updateCardioDiseaseOtherCharCount() {\n            var value = jQuery(\"#cardioDiseaseOther\").val() || \"\";\n            var length = value.length;\n            var maxLength = 250;\n            var charCountEl = jQuery(\"#cardioDiseaseOtherCharCount\");\n            var errorEl = jQuery(\"#cardioDiseaseOtherError\");\n            \n            charCountEl.text(length + \" \/ \" + maxLength + \" caract\u00e8res\");\n            \n            if (length > maxLength) {\n                charCountEl.css(\"color\", \"red\");\n                charCountEl.css(\"font-weight\", \"bold\");\n                errorEl.text(\"Ce champ d\u00e9passe la longueur maximale de \" + maxLength + \" caract\u00e8res. Veuillez raccourcir votre texte.\");\n                errorEl.show();\n                jQuery(\"#cardioDiseaseOther\").addClass(\"is-invalid\");\n            } else if (length > maxLength * 0.9) {\n                charCountEl.css(\"color\", \"orange\");\n                charCountEl.css(\"font-weight\", \"normal\");\n                errorEl.hide();\n                jQuery(\"#cardioDiseaseOther\").removeClass(\"is-invalid\");\n            } else {\n                charCountEl.css(\"color\", \"\");\n                charCountEl.css(\"font-weight\", \"normal\");\n                errorEl.hide();\n                jQuery(\"#cardioDiseaseOther\").removeClass(\"is-invalid\");\n            }\n        }\n        \n        jQuery(\"#cardioDiseaseOther\").on(\"input keyup paste\", function() {\n            updateCardioDiseaseOtherCharCount();\n        });\n        \n        \/\/ Initialize character count on page load\n        updateCardioDiseaseOtherCharCount();\n\n        \/\/TB select options stuff\n        jQuery(\"select#previousPositiveTBTest\").change(function () {\n            if (jQuery('#previousPositiveTBTest').val() == \"Yes\") {\n                jQuery(this).parent().find(\".other-section\").css(\"display\", \"block\");\n            } else {\n                jQuery(this).parent().find(\".other-section\").css(\"display\", \"none\");\n            }\n        });\n\n        jQuery(\"select#contactWithTB\").change(function () {\n            if (jQuery('#contactWithTB').val() == \"Yes\") {\n                jQuery(this).parent().find(\".other-section\").css(\"display\", \"block\");\n            } else {\n                jQuery(this).parent().find(\".other-section\").css(\"display\", \"none\");\n            }\n        });\n\n        jQuery(\"select#BCGVaccinated\").change(function () {\n            if (jQuery('#BCGVaccinated').val() == \"Yes\") {\n                jQuery(this).parent().find(\".other-section\").css(\"display\", \"block\");\n            } else {\n                jQuery(this).parent().find(\".other-section\").css(\"display\", \"none\");\n            }\n        });\n        \/\/end hide functions\n\n        jQuery('.addCountry').click(function () {\n\n            var idIndex = countryArray.indexOf(jQuery(\"#countrySearch\").val())\n            console.log(\"got index of the country searched\", idIndex);\n            if (idIndex < 0) {\n                \/\/alert(\"Veuillez s\u00e9lectionner un pays dans le menu d\u00e9roulant des r\u00e9sultats de recherche\");\n                jQuery(\"#countrySearch\").val(\"\");\n                jQuery(\"#addCountryError\").html(\n                    '<p style=\"color:red\">Veuillez s\u00e9lectionner un pays dans le menu d\u00e9roulant des r\u00e9sultats de recherche<\/p>'\n                );\n                return;\n            } else {\n                jQuery(\"#addCountryError\").html(\"\");\n            }\n\n            console.log(\"Country Search\", jQuery(\"#countrySearch\").val());\n            if (jQuery(\"#countrySearch\").val().length !== 0 || jQuery(\"#citiesVisited\").val()\n                    .length !== 0 ||\n                jQuery(\"#days\").val().length !== 0) {\n                jQuery('.repeatingSection table ').append(\"<tr><td class='countrySearchtd'>\" +\n                    jQuery(\n                        \"#countrySearch\").val() + \"<\/td>\" + \"<td class='citiesVisitedtd'>\" +\n                    jQuery(\"#citiesVisited\").val() + \"<\/td>\" + \"<td class='daystd'>\" +\n                    jQuery(\"#days\").val() + \"<\/td>\" +\n                    '<td><i class=\"far fa-trash-alt deleteCountry\"><\/i><\/td><\/tr>'\n                )\n                console.log(\"clearing searchbox\");\n                jQuery(\"#countrySearch\").val(\"\");\n                jQuery(\"#citiesVisited\").val(\"\");\n                jQuery(\"#days\").val(\"\");\n            }\n        });\n\n        \/\/ Delete a repeating section\n        jQuery(document).on('click', '.deleteCountry', function () {\n            jQuery(this).closest('tr').remove();\n            return false;\n        });\n        \"use-strict\"\n\n\n        document.getElementById('submitBtnId').addEventListener('click', function (e) {\n            e.preventDefault();\n            document.getElementById('questionnaireForm').classList.add('was-validated');\n            validateCheckboxGroups();\n            \n            let epworthValid = true;\n            \/\/ Check if Epworth section is visible and should be validated\n            const epworthSection = document.querySelector(\".sleepinessQuize\");\n            if (epworthSection && epworthSection.offsetParent !== null) {\n                \/\/ Epworth section is visible, validate all 8 questions\n                for (let i = 1; i <= 8; i++) {\n                    if (!document.querySelector(`input[name=\"question${i}\"]:checked`)) {\n                        epworthValid = false;\n                        console.log(`[DEBUG] La question ${i} de l'\u00e9chelle Epworth n'a PAS \u00e9t\u00e9 r\u00e9pondue.`);\n                        break;\n                    }\n                }\n            }\n\n            const invalidSections = getInvalidSections();\n            \n            \/\/ Debug: Show what fields are required in sleep screening section\n            console.log('[DEBUG] Sleep screening section required fields:');\n            jQuery('.sleep-screening-section').find('input[required], select[required], textarea[required]').each(function(){\n                console.log(`- ${this.type || 'select\/textarea'}: ${this.id || this.name || 'unnamed'} (valid: ${this.checkValidity()})`);\n            });\n            \n            const sleepSectionContainer = document.querySelector(\".sleepinessQuize\");\n            if (sleepSectionContainer) {\n                if (!epworthValid) {\n                    sleepSectionContainer.style.border = \"4px solid #dc3545\";\n                } else {\n                    sleepSectionContainer.style.border = \"\";\n                }\n            }\n\n            \/\/ Valider l'email avant la soumission\n            validateEmail();\n            const emailField = document.getElementById('email');\n            if (emailField.classList.contains('is-invalid')) {\n                Swal.fire({\n                    icon: 'error',\n                    title: 'Email invalide',\n                    text: 'Veuillez entrer une adresse email valide avant de soumettre.',\n                    confirmButtonText: 'OK',\n                    customClass: { confirmButton: 'btn btn-primary' },\n                    buttonsStyling: false\n                }).then(() => {\n                    emailField.scrollIntoView({ behavior: 'smooth', block: 'center' });\n                    emailField.focus();\n                });\n                return;\n            }\n\n            if (invalidSections.length > 0) {\n                let message = '<p style=\"text-align: center; font-size: 17px;\">Veuillez corriger l\\'erreur ou les erreurs avant de soumettre<\/p><ul>';\n                invalidSections.forEach(sectionName => {\n                    message += `<li style=\"text-align: left; font-size: 17px\">La section <strong>${sectionName}<\/strong> est incompl\u00e8te<\/li>`;\n                });\n                \n                \/\/ if (!epworthValid) {\n                \/\/     message += '<li>La section de l\\'<strong>\u00c9chelle de somnolence d\\'Epworth<\/strong> est incompl\u00e8te<\/li>';\n                \/\/ }\n                \n                message += '<\/ul>';\n\n                Swal.fire({\n                icon: 'error',\n                title: 'Erreur',\n                html: message,\n                confirmButtonText: 'OK',\n                customClass: {\n                    confirmButton: 'btn btn-primary' \n                },\n                buttonsStyling: false\n                }).then(() => {\n                    setTimeout(() => {\n                        const firstGroupError = document.querySelector('.question.required.has-checkbox-error');\n                        if (firstGroupError) {\n                            firstGroupError.scrollIntoView({ behavior: 'smooth', block: 'center' });\n                            return;\n                        }\n                        if (invalidSections.length > 0) {\n                        const firstInvalidSelector = sections.find(sec => sec.label === invalidSections[0]).selector;\n                        const firstInvalidField = document.querySelector(firstInvalidSelector);\n                        if (firstInvalidField) {\n                            firstInvalidField.scrollIntoView({ behavior: 'smooth', block: 'start' });\n                            firstInvalidField.focus();\n                        }\n                        }\n                    }, 300);\n                });\n                return; \n            }\n\n            dataSubmit();\n        });\n        validateCheckboxGroups();\n    }); \/\/end of document ready\n\n\n    function logInvalidFields() {\n        let invalidFields = [];\n\n        \/\/ Iterate over each required field and check if it's valid\n        jQuery('#questionnaireForm .form-control[required], #questionnaireForm input[type=\"checkbox\"][required], #questionnaireForm input[type=\"radio\"][required]').each(function () {\n            if (!this.checkValidity()) {\n                const paragraphText = jQuery(this).prevAll(\"p\").first().text().trim() || \"No associated text\";\n\n                invalidFields.push({\n                    id: this.id || this.name,\n                    type: this.type,\n                    label: jQuery(this).siblings(\"label\").text().trim() || \"Unnamed Field\",\n                    text: paragraphText\n                });\n                jQuery(this).addClass('is-invalid'); \/\/ Optional: Highlight the field\n            } else {\n                jQuery(this).removeClass('is-invalid'); \/\/ Clear invalid highlight\n            }\n        });\n\n        \/\/ Log invalid fields\n        if (invalidFields.length > 0) {\n            console.log(\"Invalid Fields:\");\n            invalidFields.forEach(field => {\n                console.log(\"text: \", field.text);\n                console.log(`Field Label: ${field.label}, Field ID\/Name: ${field.id}, Type: ${field.type}`);\n            });\n            alert(\"Veuillez corriger les champs surlign\u00e9s.\");\n        } else {\n            console.log(\"All fields are valid.\");\n            \/\/dataSubmit(); \/\/ Call dataSubmit function if all fields are valid\n        }\n    }\n<\/script>\n\n\n<script>\n    let choices = [0, 0, 0, 0, 0, 0, 0, 0]\n\n    let units = [\n        ['kg', 'lbs'],\n        ['cm', 'in']\n    ]\n\n    let chosenUnits = [0, 0]\n\n    function onAnswerChose(name, questionNumber, value) {\n        choices[questionNumber] = value\n\n        const elements = document.getElementsByName(name)\n        elements.forEach(element => {\n            element.className = 'choice'\n        });\n        elements[value].className = \"choice selectedBtn\"\n    }\n\n    function changeWeight(value, to) {\n        console.log(to)\n        return (to === 0) ? value \/ 2.2 : value * 2.2\n    }\n\n    function changeHeight(value, to) {\n        return (to === 0) ? value * 2.54 : value \/ 2.54\n    }\n\n    function onBmiUnitChange(index) {\n        chosenUnits[index] = (chosenUnits[index] + 1) % 2\n        const unitId = (index == 0) ? 'weightUnit' : 'heightUnit'\n        document.getElementById(unitId).innerText = units[index][chosenUnits[index]]\n\n        const bmiFieldId = (index == 0) ? 'bmi-weight' : 'bmi-height'\n\n        const inputField = document.getElementById(bmiFieldId)\n        let value = inputField.value\n        value = Number(value)\n\n\n        if (!isNaN(value)) {\n            if (index === 0) {\n                value = changeWeight(value, chosenUnits[index])\n            } else if (index == 1) {\n                value = changeHeight(value, chosenUnits[index])\n            }\n            inputField.value = Math.round(value * 100) \/ 100\n        }\n        \n        \/\/ Recalculate BMI after unit change\n        onBmiFieldValueChange(index);\n    }\n\n    function getStopBangData() {\n        let sum = 0;\n        choices.forEach(element => {\n            sum += element\n        });\n        let neckCircumference = parseFloat(document.getElementById('neck-circumference').value) || 0;\n\n        \/\/ Add to the STOP-BANG score if neck circumference is 40 cm or more\n        let neckCircumferenceScore = neckCircumference >= 40 ? 1 : 0;\n\n        sum += neckCircumferenceScore; \/\/ Add neck score\n        choices[6] = neckCircumferenceScore;\n        return {\n            \"choices\": choices,\n            \"sum\": sum\n        }\n    }\n\n\n    function validateStopBang() {\n        let isValid = true;\n        const questionNames = [\"first\",\"second\",\"third\",\"fourth\",\"sixth\",\"eighth\"];\n\n        questionNames.forEach(name => {\n            const choices = document.querySelectorAll('div[name=\"'+name+'\"]');\n            const answered = Array.from(choices).some(c => c.classList.contains('selectedBtn'));\n            if (!answered) {\n                isValid = false;\n                choices.forEach(c => c.classList.add('error'));\n            } else {\n                choices.forEach(c => c.classList.remove('error'));\n            }\n        });\n\n        const weightField = document.getElementById('bmi-weight');\n        const heightField = document.getElementById('bmi-height');\n        const neckField   = document.getElementById('neck-circumference');\n\n        if (!weightField.value) {\n            isValid = false;\n            weightField.classList.add('error');\n        } else {\n            weightField.classList.remove('error');\n        }\n\n        if (!heightField.value) {\n            isValid = false;\n            heightField.classList.add('error');\n        } else {\n            heightField.classList.remove('error');\n        }\n\n        if (!neckField.value) {\n            isValid = false;\n            neckField.classList.add('error');\n        } else {\n            neckField.classList.remove('error');\n        }\n\n        return isValid;\n    }\n\n    function onBmiFieldValueChange(index) {\n        let weight = document.getElementById('bmi-weight').value;\n        let height = document.getElementById('bmi-height').value;\n        let weightUnit = document.getElementById('weightUnit').innerText.trim();\n        let heightUnit = document.getElementById('heightUnit').innerText.trim();\n        let heightInput = document.getElementById('bmi-height');\n        let errorMsg = document.getElementById('height-error');\n\n        if (!errorMsg) return; \n\n        weight = Number(weight);\n        height = Number(height);\n\n        if (isNaN(height) || height <= 0) {\n            heightInput.classList.add('is-invalid');\n            heightInput.classList.remove('is-valid');\n            errorMsg.innerText = \"Veuillez entrer une grandeur valide.\";\n            errorMsg.style.display = \"block\"; \n            choices[4] = 0; \/\/ Reset BMI score if height is invalid\n            return;\n        }\n\n        let heightInInches = (heightUnit === \"cm\") ? height \/ 2.54 : height;\n\n        if (heightInInches < 48) {\n            heightInput.classList.add('is-invalid');\n            heightInput.classList.remove('is-valid');\n            errorMsg.innerText = \"La grandeur doit \u00eatre d'au moins 48 pouces.\";\n            errorMsg.style.display = \"block\"; \n            choices[4] = 0; \/\/ Reset BMI score if height is invalid\n        } else {\n            heightInput.classList.remove('is-invalid');\n            heightInput.classList.add('is-valid');\n            errorMsg.innerText = \"\"; \n            errorMsg.style.display = \"none\"; \n        }\n\n        \/\/ Calculate BMI if both weight and height are valid\n        if (weight > 0 && height > 0) {\n            \/\/ Convert weight to kg\n            let weightInKg = (weightUnit === \"lbs\") ? weight \/ 2.2 : weight;\n            \n            \/\/ Convert height to meters\n            let heightInMeters = (heightUnit === \"cm\") ? height \/ 100 : height * 0.0254;\n            \n            \/\/ Calculate BMI\n            let bmi = Math.round((weightInKg \/ (heightInMeters * heightInMeters)) * 100) \/ 100;\n            \n            \/\/ Set choices[4] based on BMI > 35\n            choices[4] = Number(bmi > 35);\n        } else {\n            choices[4] = 0; \/\/ Reset BMI score if values are invalid\n        }\n    }\n<\/script>\n\n<!--Epworth-->\n<script>\n    jQuery(document).ready(function () {\n        let a = jQuery(\"#sleepinessQuizeForm\").find(\"input[name='question1']\");\n        \/\/ console.log('val', a.value); \/\/ Check if it finds the inputs\n    });\n\n    window.addEventListener(\"load\", function () {\n        \/\/ Access the form element...\n        var form = document.getElementById(\"sleepinessQuizeForm\");\n\n        \/\/ console.log(form[\"question1\"]);\n        var errorMessage = document.getElementById('sleepinessQuizeErrorMsg');\n\n        var scoreValue = this.document.getElementById('sleepinessQuizeResultVal')\n        var scoreTitle = this.document.getElementById('sleepinessResultTitle')\n        var scoreDesc = this.document.getElementById('sleepinessResultDesc')\n    });\n\n    \/\/ ...and take over its submit event.\n    function getEpworthData() {\n        \/\/ Access the form element\n        var form = jQuery(\"#sleepinessQuizeForm\");\n\n        \/\/ Result analysis data\n        const resultsAnalysisDesc = [\n            'indicates that you do not currently have problems getting sufficient sleep. You do not suffer from daytime sleepiness',\n            'is average. This indicates that you probably currently get enough quality sleep and are not usually adversely affected by daytime sleepiness',\n            'indicates that you are sleepy. Your levels of daytime sleepiness are higher than normal.',\n            'indicates that you are excessively sleepy. You are very sleepy in the daytime and this could be an indication of a sleep disorder'\n        ];\n\n        const resultTitle = [\n            'You are not sleepy', 'Normal', 'Sleepy', 'Excessively Sleepy'\n        ];\n\n        \/\/ Initialize sum and error flag\n        let sum = 0;\n        let error = false;\n\n        \/\/ Loop through questions 1 to 8\n        for (let i = 1; i <= 8; i++) {\n            let input = form.find(\"input[name='question\" + i + \"']:checked\"); \/\/ Select checked input for each question\n            if (input.length === 0) { \/\/ Check if no option is selected\n                error = true;\n                break;\n            }\n            sum += parseInt(input.val()); \/\/ Add the value to sum\n        }\n\n        if (error) {\n            console.error(\"Please answer all questions.\");\n            return false;\n        } else {\n            \/\/ Determine message index based on the sum\n            let messageIndex = 0;\n            if (sum <= 6) {\n                messageIndex = 0;\n            } else if (sum <= 9) {\n                messageIndex = 1;\n            } else if (sum <= 17) {\n                messageIndex = 2;\n            } else {\n                messageIndex = 3;\n            }\n\n            \/\/ Access and update the result display elements\n            let scoreValue = document.getElementById('sleepinessQuizeResultVal');\n            let scoreTitle = document.getElementById('sleepinessResultTitle');\n            let scoreDesc = document.getElementById('sleepinessResultDesc');\n\n            if (scoreValue && scoreTitle && scoreDesc) {\n                scoreValue.innerText = sum;\n                scoreTitle.innerText = resultTitle[messageIndex];\n                scoreDesc.innerText = 'Your score of: ' + sum + ' ' + resultsAnalysisDesc[messageIndex];\n            }\n\n            \/\/ Return the result object\n            return {\n                \"sum\": sum,\n                \"resultTitle\": resultTitle[messageIndex],\n                \"score\": 'Your score of: ' + sum + ' ' + resultsAnalysisDesc[messageIndex]\n            };\n        }\n    }\n<\/script>\n\n<script>\n    function validateEmail() {\n        var emailField = document.getElementById('email');\n        var errorMessage = document.querySelector(\"#email + .invalid-feedback\"); \n        const emailPattern = \/^[a-zA-Z0-9._%+-]+@[a-zA-Z0-9.-]+\\.[a-zA-Z]{2,}$\/;\n\n        if (emailField.value === \"\") {\n            errorMessage.textContent = \"L'email est un champ requis\"; \n            emailField.classList.add('is-invalid');\n            emailField.classList.remove('is-valid');\n            emailField.setCustomValidity(\"\");\n        } else if (!emailPattern.test(emailField.value)) {\n            errorMessage.textContent = \"Veuillez entrer une adresse email valide\"; \n            emailField.classList.add('is-invalid');  \n            emailField.classList.remove('is-valid');\n            emailField.setCustomValidity(\"\");\n        } else {\n            emailField.classList.remove('is-invalid');\n            emailField.classList.add('is-valid');\n            emailField.setCustomValidity(\"\");\n        }\n    }\n\n    function validatePhone() {\n        var phoneField = document.getElementById('phone');\n        var errorMessage = document.querySelector(\"#phone + .invalid-feedback\");\n        const phonePattern = \/^\\+?\\d{10,15}$\/; \n        \n        \/\/ Strip dashes, spaces, and other non-digit characters (except +)\n        var cleanedValue = phoneField.value.replace(\/[^\\d+]\/g, '');\n        \n        \/\/ Update the field value if it was cleaned\n        if (cleanedValue !== phoneField.value) {\n            phoneField.value = cleanedValue;\n        }\n\n        if (phoneField.value === \"\") {\n            errorMessage.textContent = \"Le t\u00e9l\u00e9phone est un champ requis\"; \n            phoneField.classList.add('is-invalid');\n            phoneField.classList.remove('is-valid');\n            phoneField.setCustomValidity(\"\");\n        } else if (!phonePattern.test(phoneField.value)) {\n            errorMessage.textContent = \"Veuillez entrer un num\u00e9ro de t\u00e9l\u00e9phone valide (sans tirets ni espaces)\"; \n            phoneField.classList.add('is-invalid');\n            phoneField.classList.remove('is-valid');\n            phoneField.setCustomValidity(\"\");\n        } else {\n            phoneField.classList.remove('is-invalid');\n            phoneField.classList.add('is-valid');\n            phoneField.setCustomValidity(\"\");\n        }\n    }\n\n    function validateFax() {\n        var faxField = document.getElementById('pharmacyFax');\n        var errorMessage = document.querySelector(\"#pharmacyFax + .invalid-feedback\");\n        const faxPattern = \/^\\+?\\d{10,15}$\/; \n        var digits = faxField.value.replace(\/\\D\/g, '');\n\n        if (faxField.value === \"\") {\n            faxField.classList.remove('is-valid');\n            faxField.classList.remove('is-invalid');\n            errorMessage.textContent = \"\";\n            faxField.setCustomValidity(\"\");\n            return;\n        }\n\n        if (!faxPattern.test(faxField.value)) {\n            errorMessage.textContent = \"Veuillez entrer un num\u00e9ro de fax valide\"; \n            faxField.classList.add('is-invalid');\n            faxField.classList.remove('is-valid');\n            faxField.setCustomValidity(\"\");\n        } \n        else {\n            faxField.classList.add('is-valid');\n            faxField.classList.remove('is-invalid');\n            errorMessage.textContent = \"\";\n            faxField.setCustomValidity(\"\");\n        }\n    }\n<\/script>\n\n<div class=\"container\">\n    <div id=\"continueQuestionnaireContainer\" style=\"text-align:center; margin-top:30px;\">\n        <div id=\"continueQuestionnaireText\" style=\"margin-bottom:10px;\"><\/div>\n\n        <button type=\"button\" id=\"continueQuestionnaireButton\"\n                class=\"btn btn-danger continueQuestionnaireButton\">Effacer & resoumettre le questionnaire<\/button>\n    <\/div>\n\n    <div id=\"confirmNoChangesDiv\" style=\"text-align:center; margin-top:30px; display:none\">\n        <b>En tant que patient de Summit Sant\u00e9, nous avons le questionnaire m\u00e9dical rempli lors de votre derni\u00e8re visite.<\/b>\n        <div class=\"form-check\" style=\"text-align:left\">\n            <input data-clarity-unmask=\"true\" class=\"form-check-input\" type=\"checkbox\" value=\"\"\n                   id=\"confirmNoChangeCheckbox\">\n            <label class=\"form-check-label\" for=\"confirmNoChangeCheckbox\">\n                Je confirme qu'il n'y a eu aucun changement \u00e0 ma sant\u00e9 ou aux m\u00e9dicaments que je prends depuis ma derni\u00e8re visite chez Summit Sant\u00e9.\n            <\/label>\n        <\/div>\n        <button type=\"button\" id=\"confirmNoChangesButton\" class=\"btn btn-success\">Confirmer<\/button>\n        <button type=\"button\" id=\"newQuestionnaireButton\" class=\"btn btn-danger continueQuestionnaireButton\">Remplir un nouveau questionnaire<\/button>\n    <\/div>\n\n\n\n    <form method=\"POST\" class=\"needs-validation\" id=\"questionnaireForm\" novalidate>\n        <br>\n        <div class=\"main-info section\">\n            <h3><i class=\"fas fa-user\"><\/i> Information D\u00e9mographique<\/h3>\n            <div class=\"row\">\n                <div class=\"col-sm\">\n\n                    <div class=\"mb-3\">\n                        <label for=\"firstName\" class=\"form-label\">Pr\u00e9nom<span class=\"astrisc\">*<\/span><\/label>\n                        <input data-clarity-unmask=\"true\" name=\"firstName\" type=\"text\" class=\"form-control\"\n                               id=\"firstName\" required disabled>\n                        <div class=\"invalid-feedback\">\n                            Le pr\u00e9nom est un champ obligatoire\n                        <\/div>\n                    <\/div>\n                    <div class=\"mb-3\">\n                        <label for=\"lastName\" class=\"form-label\">Nom<span class=\"astrisc\">*<\/span><\/label>\n                        <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"lastName\" required\n                               disabled>\n                        <div class=\"invalid-feedback\">\n                            Le nom est un champ obligatoire\n                        <\/div>\n                    <\/div>\n\n                    <div class=\"mb-3 birthdate\">\n                        <label for=\"Birthdate\" class=\"form-label\">Date de Naissance<span class=\"astrisc\">*<\/span><\/label>\n\n                        <div class=\"input-group date\" data-provide=\"datepicker\">\n                            <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control birthdate-date-picker\"\n                                   data-date-format='yyyy-mm-dd'\n                                   placeholder=\"aaaa-mm-jj\" id=\"birthdate\" required>\n                            <div class=\"input-group-addon close-button\">\n                    <span class=\"fa fa-calendar input-group-text start_date_calendar\"\n                          aria-hidden=\"true \"><\/span>\n                                <div class=\"invalid-feedback\">\n                                    La date de naissance est un champ obligatoire\n                                <\/div>\n                            <\/div>\n                        <\/div>\n                    <\/div>\n                    <div class=\"mb-3\">\n                        <label for=\"healthCardNumber\" class=\"form-label\">Num\u00e9ro d'Assurance Maladie<\/label>\n                        <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"healthCardNumber\">\n                    <\/div>\n                    <div class=\"mb-3\">\n                        <label for=\"occupation\" class=\"form-label\">Profession<\/label>\n                        <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"occupation\">\n                    <\/div>\n                    <div class=\"mb-3\">\n                        <label for=\"country\" class=\"form-label\">Pays<\/label>\n                        <select class=\"form-select\" aria-label=\"Default select example\" id=\"country\" name=\"country\">\n                            <option selected=\"selected\" value=\"Canada\">Canada<\/option>\n                            <option value=\"USA\">\u00c9tats-Unis<\/option>\n                            <option value=\"Other\">Autre<\/option>\n                        <\/select>\n                    <\/div>\n                    <div class=\"mb-3\" id=\"provinceDiv\">\n                        <label for=\"province\" class=\"form-label\">Province<\/label>\n                        <select class=\"form-select\" aria-label=\"Default select example\" id=\"province\">\n                            <option value=\"AB\">Alberta<\/option>\n                            <option value=\"BC\">Colombie-Britannique<\/option>\n                            <option value=\"MB\">Manitoba<\/option>\n                            <option value=\"NB\">Nouveau-Brunswick<\/option>\n                            <option value=\"NL\">Terre-Neuve-et-Labrador<\/option>\n                            <option value=\"NS\">Nouvelle-\u00c9cosse<\/option>\n                            <option value=\"ON\">Ontario<\/option>\n                            <option value=\"PE\">\u00cele-du-Prince-\u00c9douard<\/option>\n                            <option value=\"QC\" selected=\"selected\">Qu\u00e9bec<\/option>\n                            <option value=\"SK\">Saskatchewan<\/option>\n                            <option value=\"NT\">Territoires du Nord-Ouest<\/option>\n                            <option value=\"NU\">Nunavut<\/option>\n                            <option value=\"YT\">Yukon<\/option>\n                        <\/select>\n                    <\/div>\n                    <div class=\"mb-3\" id=\"stateDiv\" style=\"display:none;\">\n                        <label for=\"state\" class=\"form-label\">\u00c9tat<span class=\"astrisc\">*<\/span><\/label>\n                        <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"state\">\n                        <div class=\"invalid-feedback\">\n                            L'\u00e9tat est un champ obligatoire.\n                        <\/div>\n                    <\/div>\n                <\/div>\n                <div class=\"col-sm\">\n                    <div class=\"mb-3\">\n                        <label for=\"email\" class=\"form-label\">Courriel<span class=\"astrisc\">*<\/span><\/label>\n                        <input data-clarity-unmask=\"true\" type=\"email\" class=\"form-control\" id=\"email\"\n                               placeholder=\"nom@example.ca\" required\n                               oninput=\"validateEmail()\">\n                        <div class=\"invalid-feedback\">\n                            Le courriel est un champ obligatoire\n                        <\/div>\n                    <\/div>\n\n                    <div class=\"mb-3\">\n                        <label for=\"phone\" class=\"form-label\">T\u00e9l\u00e9phone<span class=\"astrisc\">*<\/span><\/label>\n                        <input data-clarity-unmask=\"true\" type=\"phone\" class=\"form-control\" id=\"phone\" required\n                               oninput=\"validatePhone()\">\n                        <div class=\"invalid-feedback\">\n                            Le t\u00e9l\u00e9phone est un champ obligatoire\n                        <\/div>\n                    <\/div>\n\n                    <div class=\"mb-3\">\n                        <label for=\"language\" class=\"form-label\">Langue Pr\u00e9f\u00e9r\u00e9e<\/label>\n                        <select class=\"form-select\" aria-label=\"Default select example\" id=\"language\">\n                            <option value=\"English\">Anglais<\/option>\n                            <option value=\"French\" selected=\"selected\">Fran\u00e7ais<\/option>\n                        <\/select>\n                    <\/div>\n                    <div class=\"mb-3\">\n                        <label for=\"street\" class=\"form-label\">Adresse<span class=\"astrisc\">*<\/span><\/label>\n                        <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"street\" required>\n                        <div class=\"invalid-feedback\">\n                            L'adresse est un champ obligatoire\n                        <\/div>\n                    <\/div>\n                    <div class=\"mb-3\">\n                        <label for=\"city\" class=\"form-label\">Ville<span class=\"astrisc\">*<\/span><\/label>\n                        <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"city\" required>\n                        <div class=\"invalid-feedback\">\n                            La ville est un champ obligatoire\n                        <\/div>\n                    <\/div>\n                    <div class=\"mb-3\" id=\"zipCodeDiv\" style=\"display:none;\">\n                        <label for=\"zipCode\" class=\"form-label\">Code Postal<span class=\"astrisc\">*<\/span><\/label>\n                        <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"zipCode\">\n                        <div class=\"invalid-feedback\">\n                            Le Code Postal est un champ obligatoire.\n                        <\/div>\n                    <\/div>\n                    <div class=\"mb-3 postal\" id=\"postalCodeDiv\">\n                        <label for=\"postalCode\" class=\"form-label\">Code Postal<span class=\"astrisc\">*<\/span><\/label>\n                        <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"postalCode\" required>\n                        <div class=\"invalid-feedback\">\n                            Le Code Postal est un champ obligatoire.\n                        <\/div>\n                    <\/div>\n                <\/div>\n            <\/div>\n            <!-- <div class=\"row\">\n                <div class=\"col\">\n\n                <\/div>\n                <div class=\"col\">\n\n                <\/div>\n            <\/div> -->\n        <\/div>\n        <hr>\n        <div class=\"medical-section section\">\n            <h3><i class=\"fas fa-notes-medical\"><\/i> Informations m\u00e9dicales<\/h3>\n            <div class=\"question required travel-question sleep-question\">\n                <p> Avez-vous ou avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 inform\u00e9 que vous souffrez d'une maladie cardiovasculaire ?<span class=\"astrisc\">*<\/span><\/p>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"cardioDisease\" type=\"checkbox\" id=\"None\" value=\"None\">\n                    <label class=\"form-check-label\">Aucune<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"cardioDisease\" type=\"checkbox\" id=\"HighBloodPressure\" value=\"HighBloodPressure\">\n                    <label class=\"form-check-label\" for=\"HighBloodPressure\">Hypertension art\u00e9rielle<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"cardioDisease\" type=\"checkbox\" id=\"HeartFailure\" value=\"HeartFailure\">\n                    <label class=\"form-check-label\" for=\"HeartFailure\">Insuffisance cardiaque<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"cardioDisease\" type=\"checkbox\" id=\"Arrhythmia\" value=\"Arrhythmia\">\n                    <label class=\"form-check-label\" for=\"Arrhythmia\">Arythmie<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"cardioDisease\" type=\"checkbox\" id=\"Angina\" value=\"Angina\">\n                    <label class=\"form-check-label\" for=\"Angina\">Angine de poitrine<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"cardioDisease\" type=\"checkbox\" id=\"Aneurysm\" value=\"Aneurysm\">\n                    <label class=\"form-check-label\" for=\"Aneurysm\">An\u00e9vrisme<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"cardioDisease\" type=\"checkbox\" id=\"HeartAttack\" value=\"HeartAttack\">\n                    <label class=\"form-check-label\" for=\"HeartAttack\">Attaque cardiaque<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"cardioDisease\" type=\"checkbox\" id=\"Bypass\/stents\" value=\"Bypass\/stents\">\n                    <label class=\"form-check-label\" for=\"Bypass\/stents\">Pontage\/stents<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"cardioDisease\" type=\"checkbox\" id=\"Stroke\/TIA\" value=\"Stroke\/TIA\">\n                    <label class=\"form-check-label\" for=\"Stroke\/TIA\">AVC\/TIA<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"cardioDisease\" type=\"checkbox\" id=\"PulmonaryEmbolism\" value=\"PulmonaryEmbolism\">\n                    <label class=\"form-check-label\" for=\"PulmonaryEmbolism\">Embolie pulmonaire<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"cardioDisease\" type=\"checkbox\" id=\"Claudication\" value=\"Claudication\">\n                    <label class=\"form-check-label\" for=\"Claudication\">Claudication<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"cardioDisease\" type=\"checkbox\" id=\"DVT\/BloodClot\" value=\"DVT\/BloodClot\">\n                    <label class=\"form-check-label\" for=\"DVT\/BloodClot\">TVP\/Thrombose<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"cardioDisease\" type=\"checkbox\" id=\"Other\" value=\"Other\">\n                    <label class=\"form-check-label\">Autre<\/label>\n                <\/div>\n                <div class=\"mb-3 other-section\">\n                    <label for=\"cardioDiseaseOther\" class=\"form-label\">Autre<\/label>\n                    <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"cardioDiseaseOther\" maxlength=\"250\">\n                    <small class=\"form-text text-muted\" id=\"cardioDiseaseOtherCharCount\">0 \/ 250 caract\u00e8res<\/small>\n                    <div class=\"error-message\" id=\"cardioDiseaseOtherError\" style=\"display: none; color: red; margin-top: 5px;\"><\/div>\n                <\/div>\n            <\/div>\n\n\n            <div class=\"question tb-question \">\n                <p> Avez-vous ressenti l'un des sympt\u00f4mes suivants au cours de l'ann\u00e9e \u00e9coul\u00e9e ?<span class=\"astrisc\">*<\/span><\/p>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"TBSymprtoms\" type=\"checkbox\" id=\"None\" value=\"None\">\n                    <label class=\"form-check-label\">Aucun<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"TBSymprtoms\" type=\"checkbox\" id=\"Productive Cough\" value=\"Productive Cough\">\n                    <label class=\"form-check-label\" for=\"Productive Cough\">Une toux productive pendant plus de 3 semaines<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"TBSymprtoms\" type=\"checkbox\" id=\"Hemoptysis\" value=\"Hemoptysis\">\n                    <label class=\"form-check-label\" for=\"Hemoptysis\">H\u00e9moptysie (cracher du sang)<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"TBSymprtoms\" type=\"checkbox\" id=\"Weight Loss\" value=\"Weight Loss\">\n                    <label class=\"form-check-label\" for=\"Weight Loss\">Perte de poids inexpliqu\u00e9e<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"TBSymprtoms\" type=\"checkbox\" id=\"Fever\" value=\"Fever\">\n                    <label class=\"form-check-label\" for=\"Fever\">Fi\u00e8vre, frissons ou sueurs nocturnes sans raison connue<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"TBSymprtoms\" type=\"checkbox\" id=\"Shortness Of Breath\" value=\"Shortness Of Breath\">\n                    <label class=\"form-check-label\" for=\"Shortness Of Breath\">Essoufflement persistant<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"TBSymprtoms\" type=\"checkbox\" id=\"Fatigue\" value=\"Fatigue\">\n                    <label class=\"form-check-label\" for=\"Fatigue\">Fatigue inexpliqu\u00e9e<\/label>\n                <\/div>\n            <\/div>\n\n\n            <div class=\"question tb-question \">\n                <p>Avez-vous d\u00e9j\u00e0 eu un test cutan\u00e9 positif pour la tuberculose ?<span class=\"astrisc\">*<\/span><\/p>\n                <select class=\"form-select\" id=\"previousPositiveTBTest\" aria-label=\"Default select example\">\n                    <option value=\"No\">Non<\/option>\n                    <option value=\"Yes\">Oui<\/option>\n                <\/select>\n                <div class=\"mb-3 other-section\">\n                    <label for=\"previousPositiveTBTestOther\" class=\"form-label\">Quand avez-vous pass\u00e9 votre test cutan\u00e9 positif pour la tuberculose ?<\/label>\n                    <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"previousPositiveTBTestOther\">\n                <\/div>\n            <\/div>\n\n            <div class=\"question tb-question\">\n                <p>Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 en contact \u00e9troit avec quelqu'un qui \u00e9tait malade de la tuberculose ?<span class=\"astrisc\">*<\/span><\/p>\n                <select class=\"form-select\" id=\"contactWithTB\" aria-label=\"Default select example\">\n                    <option value=\"No\">Non<\/option>\n                    <option value=\"Yes\">Oui<\/option>\n                <\/select>\n                <div class=\"mb-3 other-section\">\n                    <label for=\"contactWithTBOther\" class=\"form-label\">Quand avez-vous \u00e9t\u00e9 en contact avec quelqu'un atteint de la tuberculose ?<\/label>\n                    <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"contactWithTBOther\">\n                <\/div>\n            <\/div>\n\n            <div class=\"question tb-question \">\n                <p>Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 vaccin\u00e9 avec le BCG (Bacille Calmette-Gu\u00e9rin) ?<span class=\"astrisc\">*<\/span><\/p>\n                <select class=\"form-select\" id=\"BCGVaccinated\" aria-label=\"Default select example\">\n                    <option value=\"No\">Non<\/option>\n                    <option value=\"Yes\">Oui<\/option>\n                <\/select>\n                <div class=\"mb-3 other-section\">\n                    <label for=\"BCGVaccinatedOther\" class=\"form-label\">Si oui, quand avez-vous \u00e9t\u00e9 vaccin\u00e9 ?<\/label>\n                    <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"BCGVaccinatedOther\">\n                <\/div>\n            <\/div>\n\n            <div class=\"question tb-question required\">\n                <div class=\"mb-3 \">\n                    <label for=\"reasonForTBTest\" class=\"form-label\">Pourquoi avez-vous besoin d'un test cutan\u00e9 pour la tuberculose ?<\/label>\n                    <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"reasonForTBTest\">\n                <\/div>\n            <\/div>\n\n\n\n            <div class=\"question sleep-question\">\n                <p>Avez-vous des allergies ?<span class=\"astrisc\">*<\/span><\/p>\n                <select class=\"form-select\" id=\"allergies\" aria-label=\"Default select example\">\n                    <option value=\"No Known Allergies\">Aucune allergie connue<\/option>\n                    <option value=\"Yes\">Oui<\/option>\n                    <option value=\"Seasonal Allergies\">Allergies saisonni\u00e8res<\/option>\n                <\/select>\n                <div class=\"mb-3 other-section\">\n                    <label for=\"allergiesOther\" class=\"form-label\">Allergies<\/label>\n                    <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"allergiesOther\" maxlength=\"250\">\n                    <small class=\"form-text text-muted\" id=\"allergiesOtherCharCount\">0 \/ 250 caract\u00e8res<\/small>\n                    <div class=\"error-message\" id=\"allergiesOtherError\" style=\"display: none; color: red; margin-top: 5px;\"><\/div>\n                <\/div>\n            <\/div>\n\n            <div class=\"question required travel-question sleep-question\">\n                <p>Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 inform\u00e9 que vous avez une maladie pulmonaire\/une maladie respiratoire ?<span class=\"astrisc\">*<\/span><\/p>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"respiratoryIllness\" type=\"checkbox\"\n                           id=\"None\" value=\"None\">\n                    <label class=\"form-check-label\">Aucune<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"respiratoryIllness\" type=\"checkbox\"\n                           id=\"COPD\" value=\"COPD\">\n                    <label class=\"form-check-label\" for=\"COPD\">BPCO (Bronchopneumopathie chronique obstructive)<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"respiratoryIllness\" type=\"checkbox\"\n                           id=\"Sleep Apnea\" value=\"Sleep Apnea\">\n                    <label class=\"form-check-label\" for=\"Sleep Apnea\">Apn\u00e9e du sommeil<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"respiratoryIllness\" type=\"checkbox\"\n                           id=\"Emphysema\" value=\"Emphysema\">\n                    <label class=\"form-check-label\" for=\"Emphysema\">Emphys\u00e8me<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"respiratoryIllness\" type=\"checkbox\"\n                           id=\"Chronic Bronchitis\" value=\"Chronic Bronchitis\">\n                    <label class=\"form-check-label\" for=\"Chronic Bronchitis\">Bronchite chronique<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"respiratoryIllness\" type=\"checkbox\"\n                           id=\"Asthma\" value=\"Asthma\">\n                    <label class=\"form-check-label\" for=\"Asthma\">Asthme<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"respiratoryIllness\" type=\"checkbox\"\n                           id=\"Pulmonary Fibrosis\" value=\"Pulmonary Fibrosis\">\n                    <label class=\"form-check-label\" for=\"Pulmonary Fibrosis\">Fibrose pulmonaire<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"respiratoryIllness\" type=\"checkbox\"\n                           id=\"Other\" value=\"Other\">\n                    <label class=\"form-check-label\">Autre<\/label>\n                <\/div>\n                <div class=\"mb-3 other-section\">\n                    <label for=\"respiratoryIllnessOther\" class=\"form-label\">Autre<\/label>\n                    <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"respiratoryIllnessOther\">\n                <\/div>\n            <\/div>\n\n\n\n            <div class=\"question required travel-question sleep-question\">\n                <p>Avez-vous une maladie digestive\/une maladie gastro-intestinale ?<span class=\"astrisc\">*<\/span><\/p>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"digestiveIllness\" type=\"checkbox\"\n                           id=\"None\" value=\"None\">\n                    <label class=\"form-check-label\">Aucune<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"digestiveIllness\" type=\"checkbox\"\n                           id=\"Irritablebowelsyndrome\" value=\"Irritable bowel syndrome\">\n                    <label class=\"form-check-label\" for=\"Irritablebowelsyndrome\">Syndrome du c\u00f4lon irritable<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"digestiveIllness\" type=\"checkbox\"\n                           id=\"crohn's disease\" value=\"Crohn's disease\">\n                    <label class=\"form-check-label\" for=\"crohn's disease\">Maladie de Crohn<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"digestiveIllness\" type=\"checkbox\"\n                           id=\"colitis\" value=\"Colitis\">\n                    <label class=\"form-check-label\" for=\"colitis\">Colite<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"digestiveIllness\" type=\"checkbox\"\n                           id=\"gastricreflux\" value=\"Gastric Reflux\">\n                    <label class=\"form-check-label\" for=\"gastricreflux\">Reflux gastrique<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"digestiveIllness\" type=\"checkbox\"\n                           id=\"Other\" value=\"Other\">\n                    <label class=\"form-check-label\">Autre<\/label>\n                <\/div>\n                <div class=\"mb-3 other-section\">\n                    <label for=\"digestiveIllnessOther\" class=\"form-label\">Autre<\/label>\n                    <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"digestiveIllnessOther\">\n                <\/div>\n            <\/div>\n\n            <div class=\"question required travel-question\">\n                <p>Avez-vous une maladie du foie ? Avez-vous d\u00e9j\u00e0 eu une infection \u00e0 l'h\u00e9patite ?<span class=\"astrisc\">*<\/span><\/p>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"liverDisease\" type=\"checkbox\"\n                           id=\"None\" value=\"None\">\n                    <label class=\"form-check-label\">Aucune<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"liverDisease\" type=\"checkbox\"\n                           id=\"Hepatitis A\" value=\"Hepatitis A\">\n                    <label class=\"form-check-label\" for=\"Hepatitis A\">H\u00e9patite A<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"liverDisease\" type=\"checkbox\"\n                           id=\"Hepatitis B\" value=\"Hepatitis B\">\n                    <label class=\"form-check-label\" for=\"Hepatitis B\">H\u00e9patite B<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"liverDisease\" type=\"checkbox\"\n                           id=\"Hepatitis B\" value=\"Hepatitis C\">\n                    <label class=\"form-check-label\" for=\"Hepatitis C\">H\u00e9patite C<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"liverDisease\" type=\"checkbox\"\n                           id=\"Other\" value=\"Other\">\n                    <label class=\"form-check-label\">Autre<\/label>\n                <\/div>\n                <div class=\"mb-3 other-section\">\n                    <label for=\"liverDiseaseOther\" class=\"form-label\">Autre<\/label>\n                    <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"liverDiseaseOther\">\n                <\/div>\n            <\/div>\n\n            <div class=\"question required travel-question sleep-question\">\n                <p>Avez-vous d\u00e9j\u00e0 eu des probl\u00e8mes r\u00e9naux ou avez-vous \u00e9t\u00e9 diagnostiqu\u00e9 avec une maladie r\u00e9nale ?<span class=\"astrisc\">*<\/span><\/p>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" type=\"radio\" name=\"radiokidney\"\n                           id=\"radioOther\" value=\"true\"\n                           required>\n                    <label class=\"form-check-label\" for=\"radioOther\">Oui<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" type=\"radio\" name=\"radiokidney\"\n                           id=\"radioOther\" value=\"false\"\n                           required>\n                    <label class=\"form-check-label\" for=\"radioOther\">Non<\/label>\n                <\/div>\n                <div class=\"mb-3 other-section\">\n                    <label for=\"kidneyIllnessOther\" class=\"form-label\">Veuillez pr\u00e9ciser<\/label>\n                    <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"kidneyIllnessOther\">\n                <\/div>\n            <\/div>\n\n            <div class=\"question required travel-question\">\n                <p>Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 diagnostiqu\u00e9 avec un cancer ?<span class=\"astrisc\">*<\/span><\/p>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" type=\"radio\" name=\"radioCancer\"\n                           id=\"radioOther\" value=\"true\"\n                           required>\n                    <label class=\"form-check-label\" for=\"radioOther\">Oui<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" type=\"radio\" name=\"radioCancer\"\n                           id=\"radioOther\" value=\"false\"\n                           required>\n                    <label class=\"form-check-label\" for=\"radioOther\">Non<\/label>\n                <\/div>\n                <div class=\"mb-3 other-section\">\n                    <label for=\"cancerOther\" class=\"form-label\">Veuillez pr\u00e9ciser<\/label>\n                    <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"cancerOther\">\n                <\/div>\n            <\/div>\n\n            <div class=\"question required travel-question sleep-question\">\n                <p>Avez-vous d\u00e9j\u00e0 \u00e9prouv\u00e9 ou \u00e9t\u00e9 diagnostiqu\u00e9 avec un trouble neurologique ?<span class=\"astrisc\">*<\/span><\/p>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"neurologicalDisorder\"\n                           type=\"checkbox\" id=\"None\"\n                           value=\"None\">\n                    <label class=\"form-check-label\">Aucun<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"neurologicalDisorder\"\n                           type=\"checkbox\" id=\"Epilepsy\"\n                           value=\"Epilepsy\">\n                    <label class=\"form-check-label\" for=\"Epilepsy\">\u00c9pilepsie<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"neurologicalDisorder\"\n                           type=\"checkbox\"\n                           id=\"Convulsions or Seizures\" value=\"Convulsions or Seizures\">\n                    <label class=\"form-check-label\" for=\"Convulsions or Seizures\">Convulsions ou Crises<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"neurologicalDisorder\"\n                           type=\"checkbox\" id=\"Meningitis\"\n                           value=\"Meningitis\">\n                    <label class=\"form-check-label\" for=\"Meningitis\">M\u00e9ningite<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"neurologicalDisorder\"\n                           type=\"checkbox\"\n                           id=\"Cerebral Malaria\" value=\"Cerebral Malaria\">\n                    <label class=\"form-check-label\" for=\"Cerebral Malaria\">Paludisme c\u00e9r\u00e9bral<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"neurologicalDisorder\"\n                           type=\"checkbox\" id=\"Other\"\n                           value=\"Other\">\n                    <label class=\"form-check-label\">Autre<\/label>\n                <\/div>\n                <div class=\"mb-3 other-section\">\n                    <label for=\"neurologicalDisorderOther\" class=\"form-label\">Autre<\/label>\n                    <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"neurologicalDisorderOther\">\n                <\/div>\n            <\/div>\n\n            <div class=\"question required travel-question sleep-question\">\n                <p>Avez-vous d\u00e9j\u00e0 \u00e9prouv\u00e9 ou \u00e9t\u00e9 diagnostiqu\u00e9 avec un trouble psychiatrique ?<span class=\"astrisc\">*<\/span><\/p>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"psychiatricDisorder\"\n                           type=\"checkbox\" id=\"None\"\n                           value=\"None\">\n                    <label class=\"form-check-label\">Aucun<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"psychiatricDisorder\"\n                           type=\"checkbox\" id=\"Depression\"\n                           value=\"Depression\">\n                    <label class=\"form-check-label\" for=\"Depression\">D\u00e9pression<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"psychiatricDisorder\"\n                           type=\"checkbox\" id=\"Anxiety\"\n                           value=\"Anxiety\">\n                    <label class=\"form-check-label\" for=\"Anxiety\">Anxi\u00e9t\u00e9<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"psychiatricDisorder\"\n                           type=\"checkbox\" id=\"Bipolar\"\n                           value=\"Bipolar\">\n                    <label class=\"form-check-label\" for=\"Bipolar\">Bipolaire<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"psychiatricDisorder\"\n                           type=\"checkbox\" id=\"Schizophrenia\"\n                           value=\"Schizophrenia\">\n                    <label class=\"form-check-label\" for=\"Schizophrenia\">Schizophr\u00e9nie<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"psychiatricDisorder\"\n                           type=\"checkbox\"\n                           id=\"Burnout\/Medical Leave of Absence\" value=\"Burnout\/Medical Leave of Absence\">\n                    <label class=\"form-check-label\" for=\"Burnout\/Medical Leave of Absence\">Burnout\/Cong\u00e9 de maladie<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"psychiatricDisorder\"\n                           type=\"checkbox\" id=\"Other\"\n                           value=\"Other\">\n                    <label class=\"form-check-label\">Autre<\/label>\n                <\/div>\n                <div class=\"mb-3 other-section\">\n                    <label for=\"psychiatricDisorderOther\" class=\"form-label\">Autre<\/label>\n                    <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"psychiatricDisorderOther\">\n                <\/div>\n            <\/div>\n\n            <div class=\"question required\">\n                <p>Avez-vous actuellement des troubles cutan\u00e9s ?<span class=\"astrisc\">*<\/span><\/p>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"skinDisorder\" type=\"checkbox\"\n                           id=\"None\" value=\"None\">\n                    <label class=\"form-check-label\">Aucun<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"skinDisorder\" type=\"checkbox\"\n                           id=\"Psoriasis\"\n                           value=\"Psoriasis\">\n                    <label class=\"form-check-label\" for=\"Psoriasis\">Psoriasis<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"skinDisorder\" type=\"checkbox\"\n                           id=\"Eczema\" value=\"Eczema\">\n                    <label class=\"form-check-label\" for=\"Eczema\">Ecz\u00e9ma<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"skinDisorder\" type=\"checkbox\"\n                           id=\"Other\" value=\"Other\">\n                    <label class=\"form-check-label\">Autre<\/label>\n                <\/div>\n                <div class=\"mb-3 other-section\">\n                    <label for=\"skinDisorderOther\" class=\"form-label\">Autre<\/label>\n                    <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"skinDisorderOther\">\n                <\/div>\n            <\/div>\n\n            <div class=\"question required \">\n                <p>Souffrez-vous actuellement ou avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 immunod\u00e9prim\u00e9 (syst\u00e8me immunitaire affaibli) ?<span\n                        class=\"astrisc\">*<\/span><\/p>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"immunoSuppressed\" type=\"checkbox\"\n                           id=\"None\" value=\"None\">\n                    <label class=\"form-check-label\">Aucun<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"immunoSuppressed\" type=\"checkbox\"\n                           id=\"Due to Medication\"\n                           value=\"Due to Medication\">\n                    <label class=\"form-check-label\" for=\"Due to Medication\">En raison de m\u00e9dicaments<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"immunoSuppressed\" type=\"checkbox\"\n                           id=\"Hereditary Conditions\" value=\"Hereditary Conditions\">\n                    <label class=\"form-check-label\" for=\"Hereditary Conditions\">Conditions h\u00e9r\u00e9ditaires<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"immunoSuppressed\" type=\"checkbox\"\n                           id=\"Splenectomy\"\n                           value=\"Splenectomy\">\n                    <label class=\"form-check-label\" for=\"Splenectomy\">Spl\u00e9nectomie<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"immunoSuppressed\" type=\"checkbox\"\n                           id=\"HIV\" value=\"HIV\">\n                    <label class=\"form-check-label\" for=\"HIV\">VIH<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"immunoSuppressed\" type=\"checkbox\"\n                           id=\"AIDS\" value=\"AIDS\">\n                    <label class=\"form-check-label\" for=\"AIDS\">SIDA<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"immunoSuppressed\" type=\"checkbox\"\n                           id=\"Other\"\n                           value=\"Other\">\n                    <label class=\"form-check-label\">Autre<\/label>\n                <\/div>\n                <div class=\"mb-3 other-section\">\n                    <label for=\"immunoSuppressedOther\" class=\"form-label\">Autre<\/label>\n                    <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"immunoSuppressedOther\">\n                <\/div>\n            <\/div>\n\n            <div class=\"question required travel-question sleep-question\">\n                <p>Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 diagnostiqu\u00e9 avec le diab\u00e8te ?<span class=\"astrisc\">*<\/span>\n                <\/p>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" type=\"radio\" name=\"radiodiabetes\"\n                           id=\"radioOther\" value=\"true\"\n                           required>\n                    <label class=\"form-check-label\" for=\"radiodiabetes\">Oui<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" type=\"radio\" name=\"radiodiabetes\"\n                           id=\"radioOther\" value=\"false\"\n                           required>\n                    <label class=\"form-check-label\" for=\"radioOther\">Non<\/label>\n                <\/div>\n                <div class=\"mb-3 other-section\">\n                    <label for=\"diabetesOther\" class=\"form-label\">Veuillez sp\u00e9cifier<\/label>\n                    <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"diabetesOther\">\n                <\/div>\n            <\/div>\n\n            <div class=\"mb-3 question-group sleep-question\">\n                <label for=\"chronicIllness\" class=\"form-label\">Avez-vous des conditions chroniques ou aigu\u00ebs, des troubles ou des maladies qui n'ont pas \u00e9t\u00e9 mentionn\u00e9s ci-dessus ?<span class=\"astrisc\">*<\/span><\/label>\n                <textarea class=\"form-control\" id=\"chronicIllness\" rows=\"3\" required><\/textarea>\n                <div class=\"invalid-feedback\">\n                    Ce champ est requis\n                <\/div>\n            <\/div>\n\n\n            <div class=\"maternity-section\">\n                <div class=\"mb-3 question-group\">\n                    <p class=\"travel-question\">Statut de maternit\u00e9<\/p>\n                    <select class=\"form-select travel-question\" id=\"maternity\" aria-label=\"Default select example\">\n                        <option value=\"None\">Aucun<\/option>\n                        <option value=\"I am pregnant\">Je suis enceinte<\/option>\n                        <option value=\"I am planning a pregnancy\">Je pr\u00e9vois une grossesse<\/option>\n                        <option value=\"I am breastfeeding\">J'allaite<\/option>\n                    <\/select>\n                <\/div>\n\n                <div class=\"mb-3 question-group\">\n                    <label for=\"medications\" class=\"form-label\">Prenez-vous des m\u00e9dicaments r\u00e9guliers ? Si oui, veuillez inclure tous les m\u00e9dicaments sur ordonnance, inhalateurs\/puffs, suppl\u00e9ments \u00e0 base de plantes et m\u00e9dicaments en vente libre.<span class=\"astrisc\">*<\/span><\/label>\n                    <textarea class=\"form-control\" id=\"medications\" rows=\"3\" required><\/textarea>\n                    <div class=\"invalid-feedback\">\n                        Ce champ est requis\n                    <\/div>\n                <\/div>\n                <div class=\"question required travel-question\">\n                    <p> Avez-vous re\u00e7u tous vos vaccins de l'enfance ?<\/p>\n                    <div class=\"form-check form-check-inline\">\n                        <input data-clarity-unmask=\"true\" class=\"form-check-input\" type=\"radio\" name=\"radioVaccine\" id=\"radioOther\" value=\"true\" required>\n                        <label class=\"form-check-label\">Oui<\/label>\n                    <\/div>\n                    <div class=\"form-check form-check-inline\">\n                        <input data-clarity-unmask=\"true\" class=\"form-check-input\" type=\"radio\" name=\"radioVaccine\" id=\"radioOther\" value=\"false\" required>\n                        <label class=\"form-check-label\">Non<\/label>\n                    <\/div>\n                    <div class=\"mb-3 other-section\">\n                        <label for=\"radioVaccineCountry\" class=\"form-label\">Dans quelle province\/pays avez-vous re\u00e7u vos vaccins de l'enfance ?<\/label>\n                        <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"radioVaccineCountry\" maxlength=\"255\">\n                    <\/div>\n                <\/div>\n                <div class=\"question required travel-question\">\n                    <p>Vivez-vous ou travaillez-vous en contact \u00e9troit avec les populations suivantes ?<\/p>\n                    <div class=\"form-check form-check-inline\">\n                        <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"contactPopulation\" type=\"checkbox\" id=\"None\" value=\"None\">\n                        <label class=\"form-check-label\">Aucun<\/label>\n                    <\/div>\n                    <div class=\"form-check form-check-inline\">\n                        <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"contactPopulation\" type=\"checkbox\" id=\"Babies\/Children\" value=\"Babies\/Children\">\n                        <label class=\"form-check-label\" for=\"Babies\/Children\">B\u00e9b\u00e9s\/Enfants<\/label>\n                    <\/div>\n                    <div class=\"form-check form-check-inline\">\n                        <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"contactPopulation\" type=\"checkbox\" id=\"Elderly\" value=\"Elderly\">\n                        <label class=\"form-check-label\" for=\"Elderly\">Personnes \u00e2g\u00e9es<\/label>\n                    <\/div>\n                    <div class=\"form-check form-check-inline\">\n                        <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"contactPopulation\" type=\"checkbox\" id=\"Someone with a chronic illness\" value=\"Someone with a chronic illness\">\n                        <label class=\"form-check-label\" for=\"Someone with a chronic illness\">Quelqu'un avec une maladie chronique<\/label>\n                    <\/div>\n                <\/div>\n                <div class=\"question required travel-question\">\n                    <p>Avez-vous d\u00e9j\u00e0 eu une r\u00e9action ind\u00e9sirable \u00e0 un vaccin ?<\/p>\n                    <div class=\"form-check form-check-inline\">\n                        <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"adverseReactionToVaccine\" type=\"checkbox\" id=\"None\" value=\"None\">\n                        <label class=\"form-check-label\">Aucune<\/label>\n                    <\/div>\n                    <div class=\"form-check form-check-inline\">\n                        <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"adverseReactionToVaccine\" type=\"checkbox\" id=\"Anaphylactic Shock\" value=\"Anaphylactic Shock\">\n                        <label class=\"form-check-label\" for=\"Anaphylactic Shock\">Choc anaphylactique<\/label>\n                    <\/div>\n                    <div class=\"form-check form-check-inline\">\n                        <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"adverseReactionToVaccine\" type=\"checkbox\" id=\"Vasovagal\" value=\"Vasovagal\">\n                        <label class=\"form-check-label\" for=\"Vasovagal\">Vasovagal<\/label>\n                    <\/div>\n                    <div class=\"form-check form-check-inline\">\n                        <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"adverseReactionToVaccine\" type=\"checkbox\" id=\"Other\" value=\"Other\">\n                        <label class=\"form-check-label\">Autre<\/label>\n                    <\/div>\n                    <div class=\"mb-3 other-section\">\n                        <label for=\"adverseReactionToVaccineOther\" class=\"form-label\">Autre<\/label>\n                        <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"adverseReactionToVaccineOther\">\n                    <\/div>\n                <\/div>\n                <div class=\"question required travel-question\">\n                    <p style=\"margin-top: 10px; margin-bottom: 3px;\">Fumez-vous des cigarettes ?<\/p>\n                    <div class=\"form-check form-check-inline\">\n                        <input data-clarity-unmask=\"true\" class=\"form-check-input\" type=\"radio\" name=\"radioSmoke\" id=\"radioSmoke\" value=\"true\" required>\n                        <label class=\"form-check-label\" for=\"radioSmoke\">Oui<\/label>\n                    <\/div>\n                    <div class=\"form-check form-check-inline\">\n                        <input data-clarity-unmask=\"true\" class=\"form-check-input\" type=\"radio\" name=\"radioSmoke\" id=\"radioSmoke\" value=\"false\" required>\n                        <label class=\"form-check-label\" for=\"radioSmoke\">Non<\/label>\n                    <\/div>\n                <\/div>\n            <\/div>\n\n            <div class=\"question required sleep-question only-sleep-question\">\n                <h3 class=\"h5\">Sympt\u00f4mes du sommeil<\/h3>\n                <p class=\"mb-2\">S\u00e9lectionnez les sympt\u00f4mes qui correspondent \u00e0 votre situation actuelle :<span class=\"astrisc\">*<\/span><\/p>\n\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"sleepSymptoms\" type=\"checkbox\" id=\"snoring\" value=\"Snoring\">\n                    <label class=\"form-check-label\" for=\"snoring\">Ronflements<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"sleepSymptoms\" type=\"checkbox\" id=\"restlessSleep\" value=\"Restless sleep\">\n                    <label class=\"form-check-label\" for=\"restlessSleep\">Sommeil agit\u00e9<\/label>\n                <\/div>\n\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"sleepSymptoms\" type=\"checkbox\" id=\"daytimeDrowsiness\" value=\"Daytime drowsiness\">\n                    <label class=\"form-check-label\" for=\"daytimeDrowsiness\">Somnolence diurne<\/label>\n                <\/div>\n\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"sleepSymptoms\" type=\"checkbox\" id=\"nightSweats\" value=\"Night sweats\">\n                    <label class=\"form-check-label\" for=\"nightSweats\">Sueurs nocturnes<\/label>\n                <\/div>\n\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"sleepSymptoms\" type=\"checkbox\" id=\"observedRespiratoryArrest\" value=\"Observed respiratory arrest\">\n                    <label class=\"form-check-label\" for=\"observedRespiratoryArrest\">Arr\u00eat respiratoire observ\u00e9<\/label>\n                <\/div>\n\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"sleepSymptoms\" type=\"checkbox\" id=\"memoryLoss\" value=\"Memory loss\">\n                    <label class=\"form-check-label\" for=\"memoryLoss\">Perte de m\u00e9moire<\/label>\n                <\/div>\n\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"sleepSymptoms\" type=\"checkbox\" id=\"tiredUponAwakening\" value=\"Tired upon awakening\">\n                    <label class=\"form-check-label\" for=\"tiredUponAwakening\">Fatigu\u00e9 au r\u00e9veil<\/label>\n                <\/div>\n\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"sleepSymptoms\" type=\"checkbox\" id=\"irritability\" value=\"Irritability\">\n                    <label class=\"form-check-label\" for=\"irritability\">Irritabilit\u00e9<\/label>\n                <\/div>\n\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"sleepSymptoms\" type=\"checkbox\" id=\"headacheMorning\" value=\"Headache in the morning\">\n                    <label class=\"form-check-label\" for=\"headacheMorning\">Maux de t\u00eate le matin<\/label>\n                <\/div>\n\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"sleepSymptoms\" type=\"checkbox\" id=\"lackOfConcentration\" value=\"Lack of concentration\">\n                    <label class=\"form-check-label\" for=\"lackOfConcentration\">Manque de concentration<\/label>\n                <\/div>\n\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"sleepSymptoms\" type=\"checkbox\" id=\"difficultyBreathingNight\" value=\"Difficulty breathing at night\">\n                    <label class=\"form-check-label\" for=\"difficultyBreathingNight\">Difficult\u00e9 \u00e0 respirer la nuit<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"sleepSymptoms\" type=\"checkbox\" id=\"jawPain\" value=\"Jaw pain\">\n                    <label class=\"form-check-label\" for=\"jawPain\">Douleur \u00e0 la m\u00e2choire<\/label>\n                <\/div>\n\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"sleepSymptoms\" type=\"checkbox\" id=\"chokingAwakening\" value=\"Choking with awakening during sleep\">\n                    <label class=\"form-check-label\" for=\"chokingAwakening\">S'\u00e9touffer au r\u00e9veil pendant le sommeil<\/label>\n                <\/div>\n\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"sleepSymptoms\" type=\"checkbox\" id=\"grindTeeth\" value=\"Grind your teeth or clench your jaw\">\n                    <label class=\"form-check-label\" for=\"grindTeeth\">Grincer des dents ou serrer la m\u00e2choire<\/label>\n                <\/div>\n\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"sleepSymptoms\" type=\"checkbox\" id=\"frequentAwakening\" value=\"Frequent awakening\">\n                    <label class=\"form-check-label\" for=\"frequentAwakening\">R\u00e9veils fr\u00e9quents<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"sleepSymptoms\" type=\"checkbox\" id=\"nonRestorativeSleep\" value=\"Non-restorative sleep\">\n                    <label class=\"form-check-label\" for=\"nonRestorativeSleep\">Sommeil non r\u00e9parateur<\/label>\n                <\/div>\n            <\/div>\n\n        <\/div>\n        <hr>\n\n        <div class=\"lifestyle-section section\">\n            <h3><i class=\"fas fa-heartbeat\"><\/i> Informations sur le mode de vie<\/h3>\n\n            <!-- <p> Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 diagnostiqu\u00e9 avec le diab\u00e8te ?<span class=\"astrisc\">*<\/span>\n            <\/p> -->\n\n            <!-- Section Tabac -->\n            <div class=\"question required sleep-question\">\n                <p class=\"mb-3 h5\">Tabac<\/p>\n                <div class=\"mb-3\">\n                    <p class=\"mb-0\">Avez-vous d\u00e9j\u00e0 fum\u00e9 ?<span class=\"astrisc\">*<\/span><\/p>\n                    <div class=\"form-check form-check-inline\">\n                        <input data-clarity-unmask=\"true\" class=\"form-check-input smoke-ever\" type=\"radio\"\n                               name=\"everSmoke\" value=\"no\" required>\n                        <label class=\"form-check-label\">Non<\/label>\n                    <\/div>\n                    <div class=\"form-check form-check-inline\">\n                        <input data-clarity-unmask=\"true\" class=\"form-check-input smoke-ever\" type=\"radio\"\n                               name=\"everSmoke\" value=\"yes\" required>\n                        <label class=\"form-check-label\">Oui<\/label>\n                    <\/div>\n                <\/div>\n                <!-- Question conditionnelle : \"Fumez-vous toujours ?\" -->\n                <div class=\"still-smoking-question mb-3\" style=\"display: none;\">\n                    <p class=\"mb-0\">Fumez-vous toujours ?<span class=\"astrisc\">*<\/span><\/p>\n                    <div class=\"form-check form-check-inline\">\n                        <input data-clarity-unmask=\"true\" class=\"form-check-input smoke-still\" type=\"radio\"\n                               name=\"stillSmoking\" value=\"no\" required>\n                        <label class=\"form-check-label\">Non<\/label>\n                    <\/div>\n                    <div class=\"form-check form-check-inline\">\n                        <input data-clarity-unmask=\"true\" class=\"form-check-input smoke-still\" type=\"radio\"\n                               name=\"stillSmoking\" value=\"yes\" required>\n                        <label class=\"form-check-label\">Oui<\/label>\n                    <\/div>\n                <\/div>\n\n                <!-- Questions conditionnelles sur le tabac -->\n                <div class=\"tobacco-details\" style=\"display: none;\">\n\n                    <div class=\"mb-3\">\n                        <label for=\"cigarettesPerDay\" class=\"form-label\">Combien de cigarettes fumez-vous par jour ?<\/label>\n                        <input data-clarity-unmask=\"true\" type=\"number\" class=\"form-control\" id=\"cigarettesPerDay\"\n                               name=\"cigarettesPerDay\">\n                        <div class=\"invalid-feedback\">\n                            Ce champ est obligatoire\n                        <\/div>\n                    <\/div>\n                    <div class=\"mb-3\">\n                        <label for=\"yearsSmoking\" class=\"form-label\">Depuis combien d'ann\u00e9es fumez-vous ?<\/label>\n                        <input data-clarity-unmask=\"true\" type=\"number\" class=\"form-control\" id=\"yearsSmoking\"\n                               name=\"yearsSmoking\">\n                        <div class=\"invalid-feedback\">\n                            Ce champ est obligatoire\n                        <\/div>\n                    <\/div>\n                    <div class=\"mb-3\">\n                        <label for=\"yearsStopped\" class=\"form-label\">Depuis combien de temps avez-vous arr\u00eat\u00e9 de fumer ? (si\n                            applicable)<\/label>\n                        <input data-clarity-unmask=\"true\" type=\"number\" class=\"form-control\" id=\"yearsStopped\"\n                               name=\"yearsStopped\">\n                        <div class=\"invalid-feedback\">\n                            Ce champ est obligatoire\n                        <\/div>\n                    <\/div>\n                <\/div>\n            <\/div>\n\n            <!-- Section Alcool -->\n            <div class=\"question required sleep-question\">\n                <p class=\"mb-3 h5\">Alcool<\/p>\n                <div class=\"mb-3\">\n                    <p class=\"mb-0\">Consommez-vous r\u00e9guli\u00e8rement de l'alcool (vin, bi\u00e8re et\/ou spiritueux) ?<span\n                            class=\"astrisc\">*<\/span>\n                    <\/p>\n                    <div class=\"form-check form-check-inline\">\n                        <input data-clarity-unmask=\"true\" class=\"form-check-input alcohol-answer\" type=\"radio\"\n                               name=\"alcohol\" value=\"no\" required>\n                        <label class=\"form-check-label\">Non<\/label>\n                    <\/div>\n                    <div class=\"form-check form-check-inline\">\n                        <input data-clarity-unmask=\"true\" class=\"form-check-input alcohol-answer\" type=\"radio\"\n                               name=\"alcohol\" value=\"yes\" required>\n                        <label class=\"form-check-label\">Oui<\/label>\n                    <\/div>\n                <\/div>\n\n                <!-- Questions conditionnelles sur l'alcool -->\n                <div class=\"alcohol-details\" style=\"display: none;\">\n                    <p class=\"mb-0\">Si oui, \u00e0 quel moment de la journ\u00e9e ?<span class=\"astrisc\">*<\/span><\/p>\n                    <div class=\"form-check form-check-inline\">\n                        <input data-clarity-unmask=\"true\" class=\"form-check-input\" type=\"checkbox\" name=\"timeOfDay\"\n                               value=\"lunch\">\n                        <label class=\"form-check-label\">D\u00e9jeuner<\/label>\n                    <\/div>\n                    <div class=\"form-check form-check-inline\">\n                        <input data-clarity-unmask=\"true\" class=\"form-check-input\" type=\"checkbox\" name=\"timeOfDay\"\n                               value=\"dinner\">\n                        <label class=\"form-check-label\">D\u00eener<\/label>\n                    <\/div>\n                    <div class=\"form-check form-check-inline\">\n                        <input data-clarity-unmask=\"true\" class=\"form-check-input\" type=\"checkbox\" name=\"timeOfDay\"\n                               value=\"evening\">\n                        <label class=\"form-check-label\">Soir\u00e9e<\/label>\n                    <\/div>\n                    <div class=\"mb-3\">\n                        <label for=\"drinksPerWeek\" class=\"form-label\">Nombre de verres par semaine :<span\n                                class=\"astrisc\">*<\/span><\/label>\n                        <input data-clarity-unmask=\"true\" type=\"number\" class=\"form-control\" id=\"drinksPerWeek\"\n                               name=\"drinksPerWeek\">\n                        <div class=\"invalid-feedback\">\n                            Ce champ est obligatoire\n                        <\/div>\n                    <\/div>\n                <\/div>\n            <\/div>\n\n            <!-- Section Drogues -->\n            <div class=\"question required sleep-question\">\n                <p class=\"mb-3 h5\">Drogues<\/p>\n                <p>Consommez-vous des drogues (y compris des somnif\u00e8res) ?<span class=\"astrisc\">*<\/span><\/p>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input drugs-answer\" type=\"radio\" name=\"drugs\"\n                           value=\"no\" required>\n                    <label class=\"form-check-label\">Non<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input drugs-answer\" type=\"radio\" name=\"drugs\"\n                           value=\"yes\" required>\n                    <label class=\"form-check-label\">Oui<\/label>\n                <\/div>\n\n                <!-- Question conditionnelle sur les drogues -->\n                <div class=\"drugs-details\" style=\"display: none;\">\n                    <label for=\"drugType\" class=\"form-label\">Si oui, quelles drogues :<span class=\"astrisc\">*<\/span><\/label>\n                    <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"drugType\" name=\"drugType\" maxlength=\"250\">\n                    <div class=\"invalid-feedback\">\n                        Ce champ est obligatoire\n                    <\/div>\n                <\/div>\n            <\/div>\n            \n            <!-- Section cafe -->\n            <div class=\"question required travel-question\">\n                <p class=\"mb-3 h5\">Caf\u00e9<\/p>\n                <p style=\"margin-top: 10px; margin-bottom: 3px;\">\n                    Combien de tasses de caf\u00e9 bois-tu par jour ?<span class=\"astrisc\">*<\/span>\n                <\/p>\n                <div class=\"mb-3\">\n                    <input data-clarity-unmask=\"true\" type=\"number\" class=\"form-control\" id=\"coffeeCupsPerDay\"\n                        name=\"coffeeCupsPerDay\" min=\"0\" placeholder=\"\" required \/>\n                    <div class=\"invalid-feedback\">\n                        Ce champ est obligatoire\n                    <\/div>\n                <\/div>\n            <\/div>\n        <\/div>\n\n            <hr>\n            <div class=\"referrer-section section\">\n                <h3><i class=\"fas fa-user-md\"><\/i> Informations sur le r\u00e9f\u00e9rent<\/h3>\n                <p class=\"subtitle\">\n                Si vous avez \u00e9t\u00e9 r\u00e9f\u00e9r\u00e9 par votre m\u00e9decin ou votre dentiste, veuillez fournir leurs informations afin que nous puissions leur transmettre directement vos r\u00e9sultats. Si vous n'avez pas \u00e9t\u00e9 r\u00e9f\u00e9r\u00e9, mais souhaitez tout de m\u00eame que nous leur envoyions vos r\u00e9sultats, veuillez remplir leurs coordonn\u00e9es et nous serons ravis d'accommoder votre demande.\n            <\/p>\n            <div class=\"row\">\n                <div class=\"col-md-6 mb-3\">\n                    <label for=\"doctorFirstName\" class=\"form-label\">Pr\u00e9nom du m\u00e9decin<\/label>\n                    <input type=\"text\" class=\"form-control\" id=\"doctorFirstName\" name=\"doctorFirstName\">\n                <\/div>\n                <div class=\"col-md-6 mb-3\">\n                    <label for=\"doctorLastName\" class=\"form-label\">Nom de famille du m\u00e9decin<\/label>\n                    <input type=\"text\" class=\"form-control\" id=\"doctorLastName\" name=\"doctorLastName\" onblur=\"handleSearch('Doctor')\">\n                <\/div>\n            <\/div>\n            <div class=\"row\">\n                <div class=\"col-md-6 mb-3\">\n                    <label for=\"dentistFirstName\" class=\"form-label\">Pr\u00e9nom du dentiste<\/label>\n                    <input type=\"text\" class=\"form-control\" id=\"dentistFirstName\" name=\"dentistFirstName\">\n                <\/div>\n                <div class=\"col-md-6 mb-3\">\n                    <label for=\"dentistLastName\" class=\"form-label\">Nom de famille du dentiste<\/label>\n                    <input type=\"text\" class=\"form-control\" id=\"dentistLastName\" name=\"dentistLastName\" onblur=\"handleSearch('Dentist')\">\n                <\/div>\n            <\/div>\n        \n            <!-- Modal for Selection -->\n            <div class=\"modal fade\" id=\"selectionModal\" tabindex=\"-1\" aria-hidden=\"true\">\n                <div class=\"modal-dialog modal-lg\">\n                    <div class=\"modal-content\">\n                        <div class=\"modal-header\">\n                            <div>\n                                <h5 class=\"modal-title\">Veuillez pr\u00e9ciser votre r\u00e9f\u00e9rent<\/h5>\n                                <p class=\"subtitle\">\n                                    Veuillez s\u00e9lectionner votre r\u00e9f\u00e9rent dans la liste ci-dessous afin que nous puissions leur transmettre vos r\u00e9sultats avec pr\u00e9cision une fois votre test termin\u00e9.\n                                <\/p>\n                            <\/div>\n                            <button type=\"button\" class=\"btn-close\" data-bs-dismiss=\"modal\" aria-label=\"Fermer\"><\/button>\n                        <\/div>\n                        <div class=\"modal-body\">\n                            <div id=\"professionalOptions\"><\/div>\n                        <\/div>\n                        <div class=\"modal-footer\">\n                            <button type=\"button\" class=\"btn btn-secondary\" data-bs-dismiss=\"modal\">Enregistrer et fermer<\/button>\n                            <button type=\"button\" class=\"btn btn-secondary\" data-bs-dismiss=\"modal\">Mon m\u00e9decin ne figure pas dans la liste<\/button>\n                        <\/div>\n                    <\/div>\n                <\/div>\n            <\/div>\n        <\/div>\n        \n        <script>\n            const API_URL = 'https:\/\/api.summittravelhealthdev.com\/v1\/questionnaire\/getReferringProfessionals';\n            const RECORD_TYPE = '012OJ000001de9uYAA';\n        \n            function handleSearch(professionalType) {\n                const firstName = document.getElementById(`${professionalType.toLowerCase()}FirstName`).value.trim();\n                const lastName = document.getElementById(`${professionalType.toLowerCase()}LastName`).value.trim();\n        \n                if (!lastName) return;\n        \n                fetch(API_URL, {\n                    method: 'POST',\n                    headers: { 'Content-Type': 'application\/json' },\n                    body: JSON.stringify({\n                        firstName,\n                        lastName,\n                        recordType: RECORD_TYPE,\n                        professionalType,\n                    }),\n                })\n                .then((response) => response.json())\n                .then((data) => displayProfessionalOptions(data, professionalType))\n                .catch((error) => console.error(`Erreur lors de la r\u00e9cup\u00e9ration des ${professionalType}s:`, error));\n            }\n        \n            function displayProfessionalOptions(professionals, professionalType) {\n                const optionsContainer = document.getElementById('professionalOptions');\n                optionsContainer.innerHTML = '';\n        \n                const modalTitle = document.querySelector('.modal-title');\n                const notInListButton = document.querySelector('#selectionModal .btn-secondary:last-of-type');\n                const saveCloseButton = document.querySelector('#selectionModal .btn-secondary:first-of-type');\n        \n                modalTitle.textContent = `Veuillez pr\u00e9ciser votre ${professionalType}`;\n                notInListButton.textContent = `Mon ${professionalType} ne figure pas dans la liste`;\n        \n                if (professionals.length === 0) {\n                    optionsContainer.innerHTML = `<p>Aucun ${professionalType} trouv\u00e9. Le formulaire sera soumis sans ID.<\/p>`;\n                } else {\n                    professionals.forEach((professional, index) => {\n                        const isChecked = index === 0 ? 'checked' : '';\n                        optionsContainer.innerHTML += `\n                            <div class=\"mb-3\">\n                                <input type=\"radio\" id=\"${professional.id}\" name=\"${professionalType.toLowerCase()}Selection\" value=\"${professional.id}\" ${isChecked}>\n                                <label for=\"${professional.id}\">\n                                    ${professional.firstName} ${professional.lastName} - ${professional.billingAddress.street}, ${professional.billingAddress.city}, ${professional.billingAddress.state}, ${professional.billingAddress.postalCode}\n                                <\/label>\n                            <\/div>\n                        `;\n                    });\n                }\n        \n                saveCloseButton.onclick = () => {\n                    const selectedId = document.querySelector(`input[name=\"${professionalType.toLowerCase()}Selection\"]:checked`)?.value || null;\n                    if (professionalType === 'Doctor') {\n                        document.getElementById('doctorFirstName').dataset.id = selectedId;\n                        selectedDoctorId = selectedId\n                        console.log(\"doctor selected:\" + selectedId)\n                    } else if (professionalType === 'Dentist') {\n                        document.getElementById('dentistFirstName').dataset.id = selectedId;\n                        selectedDentistId = selectedId\n                    }\n                };\n        \n                notInListButton.onclick = () => {\n                    if (professionalType === 'Doctor') {\n                        document.getElementById('doctorFirstName').dataset.id = null;\n                    } else if (professionalType === 'Dentist') {\n                        document.getElementById('dentistFirstName').dataset.id = null;\n                    }\n                };\n        \n                const modal = new bootstrap.Modal(document.getElementById('selectionModal'));\n                if (professionals.length !== 0) {\n                    modal.show();\n                }\n            }\n        <\/script>\n        <hr>\n\n        <div class=\"sleep-screening-section section\">\n            <h3><i class=\"fas fa-heartbeat\"><\/i> D\u00e9pistage du sommeil<\/h3>\n\n            <!-- StopBang -->\n            <div class=\"mt-3\">\n                <div class=\"OSAQuizeWrapper\">\n                    <div id=\"OSAQuizeForm\">\n                        <h3 class=\"h4\">Est-il possible que vous ayez de l'apn\u00e9e obstructive du sommeil (AOS) ?<\/h3>\n                        <p class=\"text-muted mb-3\">Le questionnaire STOP BANG est un outil de d\u00e9pistage \u00e9prouv\u00e9 utilis\u00e9\n                            pour d\u00e9terminer la probabilit\u00e9 d'avoir une apn\u00e9e obstructive du sommeil (AOS). Ces questions\n                            vous aideront \u00e0 d\u00e9terminer si vous \u00eates \u00e0 faible, moyen ou haut risque pour l'apn\u00e9e du sommeil.<\/p>\n\n                        <div class=\"singleQuestion\">\n\n                            <div class=\"questionWrapper\">\n                                <span class=\"questionTitle\">Ronflez-vous bruyamment ?<\/span><br\/>\n                                <span class=\"quesitonDesc\">Plus fort que la parole ou assez fort pour \u00eatre entendu \u00e0 travers des portes ferm\u00e9es<\/span>\n                            <\/div>\n\n                            <div class=\"inputWrapper\">\n                                <div name=\"first\" onclick=\"onAnswerChose('first',0,0)\" class=\"choice selectedBtn\">NON<\/div>\n                                <div name=\"first\" onclick=\"onAnswerChose('first',0,1)\" class=\"choice\">OUI<\/div>\n                            <\/div>\n                        <\/div>\n\n                        <div class=\"singleQuestion\">\n\n                            <div class=\"questionWrapper\">\n                                <span class=\"questionTitle\">Ressentez-vous souvent de la fatigue, de la somnolence ou de la somnolence pendant la journ\u00e9e ?<\/span><br\/>\n                            <\/div>\n\n                            <div class=\"inputWrapper\">\n                                <div name=\"second\" onclick=\"onAnswerChose('second',1,0)\" class=\"choice selectedBtn\">NON<\/div>\n                                <div name=\"second\" onclick=\"onAnswerChose('second',1,1)\" class=\"choice\">OUI<\/div>\n                            <\/div>\n                        <\/div>\n\n                        <div class=\"singleQuestion\">\n\n                            <div class=\"questionWrapper\">\n                                <span class=\"questionTitle\">Quelqu'un vous a-t-il observ\u00e9 arr\u00eater de respirer pendant votre sommeil ?<\/span><br\/>\n                            <\/div>\n\n                            <div class=\"inputWrapper\">\n                                <div name=\"third\" onclick=\"onAnswerChose('third',2,0)\" class=\"choice selectedBtn\">NON<\/div>\n                                <div name=\"third\" onclick=\"onAnswerChose('third',2,1)\" class=\"choice\">OUI<\/div>\n                            <\/div>\n                        <\/div>\n\n                        <div class=\"singleQuestion\">\n\n                            <div class=\"questionWrapper\">\n                                <span class=\"questionTitle\">Avez-vous (ou \u00eates-vous trait\u00e9 pour) une hypertension art\u00e9rielle ?<\/span><br\/>\n                            <\/div>\n\n                            <div class=\"inputWrapper\">\n                                <div name=\"fourth\" onclick=\"onAnswerChose('fourth',3,0)\" class=\"choice selectedBtn\">NON<\/div>\n                                <div name=\"fourth\" onclick=\"onAnswerChose('fourth',3,1)\" class=\"choice\">OUI<\/div>\n                            <\/div>\n                        <\/div>\n\n                        <div class=\"singleQuestion\">\n\n                            <div class=\"questionWrapper\">\n                                <span class=\"questionTitle\">IMC<\/span><br\/>\n                            <\/div>\n\n                            <div class=\"inputWrapper\">\n\n                                <div class=\"bmi-filed-wrapper\">\n                                    <input type=\"number\" placeholder=\"poids\" id=\"bmi-weight\"\n                                           onkeyup=\"onBmiFieldValueChange(0)\" class=\"form-control\" step=\"0.1\" \/>\n                                    <div onclick=\"onBmiUnitChange(0)\">\n                                        <span id=\"weightUnit\">kg<\/span>\n                                        <svg fill=\"#106fad\"\n                                             style=\"width:13px;vertical-align:middle;margin-left:5px;cursor:pointer;\"\n                                             viewBox=\"0 0 13 13\" data-reactid=\"243\">\n                                            <path\n                                                    d=\"M12,6H1C0.6,6,0.3,5.8,0.1,5.5s-0.2-0.7,0-1l2.3-4c0.3-0.5,1-0.6,1.4-0.4C4.3,0.4,4.5,1,4.2,1.5L2.7,4H12c0.6,0,1,0.4,1,1 S12.6,6,12,6z\"\n                                                    data-reactid=\"244\"><\/path>\n                                            <path\n                                                    d=\"M1,7h11c0.4,0,0.7,0.2,0.9,0.5s0.2,0.7,0,1l-2.3,4c-0.3,0.5-0.9,0.6-1.4,0.4c-0.5-0.3-0.6-0.9-0.4-1.4L10.3,9H1   C0.4,9,0,8.6,0,8S0.4,7,1,7z\"\n                                                    data-reactid=\"245\"><\/path>\n                                        <\/svg>\n                                    <\/div>\n                                <\/div>\n\n                                <div class=\"bmi-filed-wrapper\">\n                                    <input type=\"number\" placeholder=\"taille\" id=\"bmi-height\"\n                                           onkeyup=\"onBmiFieldValueChange(1)\" class=\"form-control\" step=\"0.1\" \/>\n                                    <div onclick=\"onBmiUnitChange(1)\">\n                                        <span id=\"heightUnit\">cm<\/span>\n                                        <svg fill=\"#106fad\"\n                                             style=\"width:13px;vertical-align:middle;margin-left:5px;cursor:pointer;\"\n                                             viewBox=\"0 0 13 13\" data-reactid=\"243\">\n                                            <path\n                                                    d=\"M12,6H1C0.6,6,0.3,5.8,0.1,5.5s-0.2-0.7,0-1l2.3-4c0.3-0.5,1-0.6,1.4-0.4C4.3,0.4,4.5,1,4.2,1.5L2.7,4H12c0.6,0,1,0.4,1,1 S12.6,6,12,6z\"\n                                                    data-reactid=\"244\"><\/path>\n                                            <path\n                                                    d=\"M1,7h11c0.4,0,0.7,0.2,0.9,0.5s0.2,0.7,0,1l-2.3,4c-0.3,0.5-0.9,0.6-1.4,0.4c-0.5-0.3-0.6-0.9-0.4-1.4L10.3,9H1   C0.4,9,0,8.6,0,8S0.4,7,1,7z\"\n                                                    data-reactid=\"245\"><\/path>\n                                        <\/svg>\n                                    <\/div>\n                                <\/div>\n                                <div id=\"height-error\" class=\"invalid-feedback\" style=\"display: none; color: #dc3545;\"><\/div>\n                            <\/div>\n                        <\/div>\n\n                        <!-- <div class=\"singleQuestion\">\n                            <div class=\"questionWrapper\">\n                                <span class=\"questionTitle\">\u00c2ge<\/span><br\/>\n                            <\/div>\n\n                            <div class=\"inputWrapper\">\n                                <div name=\"sixth\" onclick=\"onAnswerChose('sixth',5,0)\" class=\"choice selectedBtn\">\u226450\n                                    ans\n                                <\/div>\n                                <div name=\"sixth\" onclick=\"onAnswerChose('sixth',5,1)\" class=\"choice\">>50 ans<\/div>\n                            <\/div>\n                        <\/div> -->\n\n                        <div class=\"singleQuestion\">\n\n                            <div class=\"questionWrapper\">\n                                <span class=\"questionTitle\">Circonf\u00e9rence du cou (cm)<\/span><br\/>\n                            <\/div>\n\n                            <div class=\"inputWrapper\">\n                                <input type=\"number\" class=\"form-control\" id=\"neck-circumference\" min=\"0\" step=\"0.1\">\n\n                            <\/div>\n                        <\/div>\n\n                        <div class=\"singleQuestion\">\n                            <div class=\"questionWrapper\">\n                                <span class=\"questionTitle\">Sexe<\/span><br\/>\n                            <\/div>\n\n                            <div class=\"inputWrapper\">\n                                <div name=\"eighth\" onclick=\"onAnswerChose('eighth',7,0)\" class=\"choice selectedBtn\">\n                                    Femme\n                                <\/div>\n                                <div name=\"eighth\" onclick=\"onAnswerChose('eighth',7,1)\" class=\"choice\">Homme<\/div>\n                            <\/div>\n                        <\/div>\n                    <\/div>\n\n                <\/div>\n            <\/div>\n\n            <!-- Epworth -->\n            <hr>\n            <div class=\"mt-3\">\n\n                <div class=\"sleepinessQuizeWrapper\">\n                    <p>L'\u00c9chelle de Somnolence d'Epworth \u00e9value votre niveau de somnolence diurne et peut d\u00e9terminer si une\n                        consultation avec un sp\u00e9cialiste du sommeil est n\u00e9cessaire.\n                        Le questionnaire vous demande de noter votre probabilit\u00e9 de vous endormir (sur une \u00e9chelle de 0 \u00e0 3) pendant 8 activit\u00e9s courantes.\n                    <\/p>\n\n                    <p>Le total de ces scores donne votre niveau de somnolence diurne.<\/p>\n                    <div id=\"sleepinessQuizeForm\">\n                        <table class=\"sleepinessQuize\">\n                            <thead>\n                            <tr>\n                                <th><\/th>\n                                <th>Aucune chance de somnoler<\/th>\n                                <th>Faible chance de somnoler<\/th>\n                                <th>Chance mod\u00e9r\u00e9e de somnoler<\/th>\n                                <th>Grande chance de somnoler<\/th>\n                            <\/tr>\n                            <\/thead>\n                            <tbody>\n                            <tr>\n                                <td class=\"quizeQuestion\">Assis et en train de lire<\/td>\n                                <td><input type=\"radio\" name=\"question1\" value=\"0\" required><\/td>\n                                <td><input type=\"radio\" name=\"question1\" value=\"1\"><\/td>\n                                <td><input type=\"radio\" name=\"question1\" value=\"2\"><\/td>\n                                <td><input type=\"radio\" name=\"question1\" value=\"3\"><\/td>\n                            <\/tr>\n                            <tr>\n                                <td class=\"quizeQuestion\">Regarder la t\u00e9l\u00e9vision<\/td>\n                                <td><input type=\"radio\" name=\"question2\" value=\"0\" required><\/td>\n                                <td><input type=\"radio\" name=\"question2\" value=\"1\"><\/td>\n                                <td><input type=\"radio\" name=\"question2\" value=\"2\"><\/td>\n                                <td><input type=\"radio\" name=\"question2\" value=\"3\"><\/td>\n                            <\/tr>\n\n                            <tr>\n                                <td class=\"quizeQuestion\">Assis sans bouger dans un lieu public (par exemple, un th\u00e9\u00e2tre ou une r\u00e9union)<\/td>\n                                <td><input type=\"radio\" name=\"question3\" value=\"0\" required><\/td>\n                                <td><input type=\"radio\" name=\"question3\" value=\"1\"><\/td>\n                                <td><input type=\"radio\" name=\"question3\" value=\"2\"><\/td>\n                                <td><input type=\"radio\" name=\"question3\" value=\"3\"><\/td>\n                            <\/tr>\n\n                            <tr>\n                                <td class=\"quizeQuestion\">S'allonger pour se reposer l'apr\u00e8s-midi lorsque les circonstances le permettent<\/td>\n                                <td><input type=\"radio\" name=\"question4\" value=\"0\" required><\/td>\n                                <td><input type=\"radio\" name=\"question4\" value=\"1\"><\/td>\n                                <td><input type=\"radio\" name=\"question4\" value=\"2\"><\/td>\n                                <td><input type=\"radio\" name=\"question4\" value=\"3\"><\/td>\n                            <\/tr>\n\n                            <tr>\n                                <td class=\"quizeQuestion\">Assis et en train de parler \u00e0 quelqu'un<\/td>\n                                <td><input type=\"radio\" name=\"question5\" value=\"0\" required><\/td>\n                                <td><input type=\"radio\" name=\"question5\" value=\"1\"><\/td>\n                                <td><input type=\"radio\" name=\"question5\" value=\"2\"><\/td>\n                                <td><input type=\"radio\" name=\"question5\" value=\"3\"><\/td>\n                            <\/tr>\n                            <tr>\n                                <td class=\"quizeQuestion\">Assis tranquillement apr\u00e8s un d\u00e9jeuner sans alcool<\/td>\n                                <td><input type=\"radio\" name=\"question6\" value=\"0\" required><\/td>\n                                <td><input type=\"radio\" name=\"question6\" value=\"1\"><\/td>\n                                <td><input type=\"radio\" name=\"question6\" value=\"2\"><\/td>\n                                <td><input type=\"radio\" name=\"question6\" value=\"3\"><\/td>\n                            <\/tr>\n                            <tr>\n                                <td class=\"quizeQuestion\">En tant que passager dans une voiture pendant une heure sans pause<\/td>\n                                <td><input type=\"radio\" name=\"question7\" value=\"0\" required><\/td>\n                                <td><input type=\"radio\" name=\"question7\" value=\"1\"><\/td>\n                                <td><input type=\"radio\" name=\"question7\" value=\"2\"><\/td>\n                                <td><input type=\"radio\" name=\"question7\" value=\"3\"><\/td>\n                            <\/tr>\n\n                            <tr>\n                                <td class=\"quizeQuestion\">Dans une voiture, \u00e0 l'arr\u00eat pendant quelques minutes dans les embouteillages<\/td>\n                                <td><input type=\"radio\" name=\"question8\" value=\"0\" required><\/td>\n                                <td><input type=\"radio\" name=\"question8\" value=\"1\"><\/td>\n                                <td><input type=\"radio\" name=\"question8\" value=\"2\"><\/td>\n                                <td><input type=\"radio\" name=\"question8\" value=\"3\"><\/td>\n                            <\/tr>\n                            <\/tbody>\n                        <\/table>\n                    <\/div>\n\n                <\/div>\n\n            <\/div>\n\n            <!-- Newsletter subscription (Dorma sleep questionnaire only) -->\n            <div class=\"only-sleep-question mt-4\" style=\"display: flex; align-items: flex-start; gap: 10px;\">\n                <input type=\"checkbox\" id=\"newsletterSubscription\" name=\"newsletterSubscription\" checked style=\"width: 20px; height: 20px; margin-top: 4px; flex-shrink: 0;\">\n                <label for=\"newsletterSubscription\" style=\"margin-bottom: 0; font-weight: 400;\">S'abonner \u00e0 l'infolettre Dorma pour recevoir des promotions et des nouvelles de l'entreprise<\/label>\n            <\/div>\n        <\/div>\n\n\n        <hr>\n        <div class=\"destination-section section\">\n            <h3><i class=\"fas fa-map-marked\"><\/i> Informations sur la destination<\/h3>\n            <p style=\"font-weight:300; font-size:14px\">Veuillez ajouter tous les pays que vous visiterez en\n                recherchant ci-dessous et en cliquant sur \"ajouter un pays \u00e0 la liste\"<\/p>\n            <div class=\"row repeatingSection\">\n                <div class=\"col-sm\">\n                    <label for=\"exampleFormControlInput1\" class=\"form-label\">Pays<\/label>\n                    <div class=\"input-group\">\n                        <input data-clarity-unmask=\"true\" name=\"countrySelection_1\" type=\"text\"\n                               class=\"form-control countrySearch\"\n                               id=\"countrySearch\" autocomplete=\"false\" placeholder=\"Commencez \u00e0 taper...\">\n\n                        <div class=\"invalid-feedback\">\n                            Ce champ est requis\n                        <\/div>\n                    <\/div>\n                <\/div>\n                <div class=\"col-sm\">\n                    <div class=\"mb-3\">\n                        <label for=\"citiesVisited\" class=\"form-label\">Villes visit\u00e9es<\/label>\n                        <input data-clarity-unmask=\"true\" name=\"citiesVisited_1\" type=\"text\" class=\"form-control\"\n                               id=\"citiesVisited\">\n                        <div class=\"invalid-feedback\">\n                            Ce champ est requis\n                        <\/div>\n                    <\/div>\n                <\/div>\n                <div class=\"col-sm\">\n                    <div class=\"mb-3\">\n                        <label for=\"days\" class=\"form-label\">Nombre de jours dans le pays<\/label>\n                        <input data-clarity-unmask=\"true\" name=\"citiesVisited_1\" type=\"text\" class=\"form-control\"\n                               id=\"days\">\n                        <div class=\"invalid-feedback\">\n                            Ce champ est requis\n                        <\/div>\n                    <\/div>\n                <\/div>\n                <div class=\"col-sm addCountryDiv\" style=\"padding-top:30px\">\n                    <div id=\"addCountryError\"><\/div>\n                    <button type=\"button\" class=\"btn btn-primary addCountry\" id=\"#addCountry\">Ajouter un pays \u00e0\n                        la liste\n                    <\/button>\n                <\/div>\n                <table class=\"table\">\n                    <tbody>\n\n                    <\/tbody>\n                <\/table>\n\n            <\/div>\n        <\/div>\n\n\n        <hr>\n\n        <div class=\"trip-section section\">\n            <h3><i class=\"fas fa-suitcase\"><\/i> Information sur le voyage<\/h3>\n            <div class=\"mb-3 departureDate\">\n                <label for=\"departureDate\" class=\"form-label\">Date de d\u00e9part<\/label>\n                <div class=\"input-group date\" data-provide=\"datepicker\">\n                    <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control departure-date-picker\"\n                           data-date-format='yyyy-mm-dd'\n                           placeholder=\"aaaa-mm-jj\" id=\"departureDate\" required>\n                    <div class=\"input-group-addon close-button\">\n                        <span class=\"fa fa-calendar input-group-text start_date_calendar\"\n                              aria-hidden=\"true \"><\/span>\n                        <div class=\"invalid-feedback\">\n                            Ce champs est obligatoire\n                        <\/div>\n                    <\/div>\n                <\/div>\n            <\/div>\n            <div class=\"question trip-info\">\n                <p> But du voyage <\/p>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"travelPurpose\" type=\"checkbox\"\n                           id=\"Visiting Family\/Friends\" value=\"Visiting Family\/Friends\">\n                    <label class=\"form-check-label\" for=\"Visiting Family\/Friends\">Visite d'amis ou de famille<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"travelPurpose\" type=\"checkbox\"\n                           id=\"Pleasure Holiday\"\n                           value=\"Pleasure Holiday\">\n                    <label class=\"form-check-label\" for=\"Pleasure Holiday\">Plaisance<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"travelPurpose\" type=\"checkbox\"\n                           id=\"Business\"\n                           value=\"Business\">\n                    <label class=\"form-check-label\" for=\"Business\">Affaires<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"travelPurpose\" type=\"checkbox\"\n                           id=\"Volunteer Work\"\n                           value=\"Volunteer Work\">\n                    <label class=\"form-check-label\" for=\"Volunteer Work\">B\u00e9n\u00e9volat\/coop\u00e9ration<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"travelPurpose\" type=\"checkbox\"\n                           id=\"Academic\"\n                           value=\"Academic\">\n                    <label class=\"form-check-label\" for=\"Academic\">\u00c9tudes<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"travelPurpose\" type=\"checkbox\"\n                           id=\"Adoption\"\n                           value=\"Adoption\">\n                    <label class=\"form-check-label\" for=\"Adoption\">Adoption<\/label>\n                <\/div>\n            <\/div>\n            <div class=\"question trip-info\">\n                <p> Activit\u00e9s <\/p>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"travelActivities\" type=\"checkbox\"\n                           id=\"Climbing\/High Altitude\" value=\"Climbing\/High Altitude\">\n                    <label class=\"form-check-label\" for=\"Climbing\/High Altitude\">Escalade\/haute altitude<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"travelActivities\" type=\"checkbox\"\n                           id=\"Extreme Sports\"\n                           value=\"Extreme Sports\">\n                    <label class=\"form-check-label\" for=\"Extreme Sports\">Sports extr\u00eames<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"travelActivities\" type=\"checkbox\"\n                           id=\"Farming\"\n                           value=\"Farming\">\n                    <label class=\"form-check-label\" for=\"Farming\">Agriculture<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"travelActivities\" type=\"checkbox\"\n                           id=\"Healthcare\"\n                           value=\"Healthcare\">\n                    <label class=\"form-check-label\" for=\"Healthcare\">Soins de sant\u00e9<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"travelActivities\" type=\"checkbox\"\n                           id=\"Jogging\/Bicycling\"\n                           value=\"Jogging\/Bicycling\">\n                    <label class=\"form-check-label\" for=\"Jogging\/Bicycling\">Course \u00e0 pied\/v\u00e9lo<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"travelActivities\" type=\"checkbox\"\n                           id=\"Other\"\n                           value=\"Other\">\n                    <label class=\"form-check-label\">Autre<\/label>\n                <\/div>\n                <div class=\"mb-3 other-section\">\n                    <label for=\"travelActivitiesOther\" class=\"form-label\">Autre<\/label>\n                    <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"travelActivitiesOther\">\n                <\/div>\n            <\/div>\n\n            <div class=\"question trip-info\">\n                <p>Type(s) de logement <\/p>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"travelAccommodation\"\n                           type=\"checkbox\"\n                           id=\"All-inclusive resort\" value=\"All-inclusive resort\">\n                    <label class=\"form-check-label\" for=\"All-inclusive resort\">H\u00f4tel tout inclus<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"travelAccommodation\"\n                           type=\"checkbox\" id=\"Family\/Friends\"\n                           value=\"Family\/Friends\">\n                    <label class=\"form-check-label\" for=\"Family\/Friends\">Famille\/amis<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"travelAccommodation\"\n                           type=\"checkbox\" id=\"Hotel\"\n                           value=\"Hotel\">\n                    <label class=\"form-check-label\" for=\"Hotel\">H\u00f4tel<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"travelAccommodation\"\n                           type=\"checkbox\" id=\"Camping\"\n                           value=\"Camping\">\n                    <label class=\"form-check-label\" for=\"Camping\">Camping<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"travelAccommodation\"\n                           type=\"checkbox\" id=\"Villa\"\n                           value=\"Villa\">\n                    <label class=\"form-check-label\" for=\"Villa\">Villa<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"travelAccommodation\"\n                           type=\"checkbox\" id=\"Hostel\"\n                           value=\"Hostel\">\n                    <label class=\"form-check-label\" for=\"Hostel\">Auberge de jeunesse<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"travelAccommodation\"\n                           type=\"checkbox\" id=\"Apartment\"\n                           value=\"Apartment\">\n                    <label class=\"form-check-label\" for=\"Apartment\">Apartement<\/label>\n                <\/div>\n                <div class=\"form-check form-check-inline\">\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" name=\"travelAccommodation\"\n                           type=\"checkbox\" id=\"Other\"\n                           value=\"Other\">\n                    <label class=\"form-check-label\">Autre<\/label>\n                <\/div>\n                <div class=\"mb-3 other-section\">\n                    <label for=\"travelAccommodationOther\" class=\"form-label\">Autre<\/label>\n                    <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"travelAccommodationOther\">\n                <\/div>\n            <\/div>\n        <\/div>\n\n        <hr>\n        <div class=\"emergency-section section\">\n            <h3><i class=\"fas fa-phone\"><\/i> Personne \u00e0 contacter en cas d'urgence<\/h3>\n            <div class=\"row\">\n\n                <div class=\"mb-3\">\n                    <label for=\"emergencyContactName\" class=\"form-label\">Nom Complet<\/label>\n                    <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"emergencyContactName\"\n                           required>\n                    <div class=\"invalid-feedback\">\n                        Ce champs est obligatoire\n                    <\/div>\n                <\/div>\n                <div class=\"mb-3\">\n                    <label for=\"emergencyContactNumber\" class=\"form-label\">Num\u00e9ro de t\u00e9l\u00e9phone<\/label>\n                    <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"emergencyContactNumber\"\n                           required>\n                    <div class=\"invalid-feedback\">\n                        Ce champs est obligatoire\n                    <\/div>\n                <\/div>\n                <div class=\"mb-3\">\n                    <label for=\"guardianName\" class=\"form-label\">Parent ou tuteur l\u00e9gal (si applicable)<\/label>\n                    <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"guardianName\">\n                <\/div>\n            <\/div>\n        <\/div>\n        <div class=\"pharmacy-section section\" style=\"display:none\">\n            <h3><i class=\"fas fa-prescription\"><\/i> Coordonn\u00e9es de votre pharmacie<\/h3>\n            <div class=\"row\">\n                <p>Veuillez indiquer les informations relatives \u00e0 votre pharmacie afin que nous puissions envoyer les ordonnances directement \u00e0 la pharmacie de votre choix. (facultatif)<\/p>\n                <div class=\"mb-3\">\n                    <label for=\"phone\" class=\"form-label\">Nom de la pharmacie<\/label>\n                    <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"pharmacyName\"\n                           placeholder=\"e.g. Jean Coutu\">\n                    <div class=\"invalid-feedback\">\n                        Le nom de la pharmacie est obligatoire\n                    <\/div>\n                <\/div>\n                <div class=\"mb-3\">\n                    <label for=\"phone\" class=\"form-label\">Adresse de la pharmacie<\/label>\n                    <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"pharmacyStreet\"\n                           placeholder=\"e.g. 123 rue principale\">\n                    <div class=\"invalid-feedback\">\n                        L'adresse de la pharmacie est obligatoire\n                    <\/div>\n                <\/div>\n                <div class=\"mb-3\">\n                    <label for=\"phone\" class=\"form-label\">La ville de la pharmacie<\/label>\n                    <input data-clarity-unmask=\"true\" type=\"text\" class=\"form-control\" id=\"pharmacyCity\"\n                           placeholder=\"e.g. Montr\u00e9al\">\n                    <div class=\"invalid-feedback\">\n                        La ville de la pharmacie est obligatoire\n                    <\/div>\n                <\/div>\n                <div class=\"mb-3\">\n                    <label for=\"phone\" class=\"form-label\">Num\u00e9ro de fax<\/label>\n                    <input data-clarity-unmask=\"true\" type=\"phone\" class=\"form-control\" id=\"pharmacyFax\"\n                           oninput=\"validateFax()\">\n                    <div class=\"invalid-feedback\">\n                        Le num\u00e9ro de fax est obligatoire\n                    <\/div>\n                <\/div>\n            <\/div>\n        <\/div>\n\n\n        <br\/>\n\n        <div class=\"sleep-section-terms\">\n            <ul>\n                <li> Je d\u00e9clare qu\u2019au meilleur de mes connaissances, les informations mentionn\u00e9es ci-dessus sont exactes et compl\u00e8tes. Je comprends qu\u2019une fausse d\u00e9claration pourrait mettre ma sant\u00e9 en danger.\n                <\/li>\n                <li>\n                    J'accepte <a id=\"privacy-policy-link-fr\" style=\"color:black\" href=\"#\">la politique de confidentialit\u00e9 du site Web<\/a> et la \n                    <a id=\"personal-info-policy-link-fr\" style=\"color:black\" href=\"#\">politique d'informations personnelles<\/a>.\n                <\/li>\n                <li> Je comprends et accepte que les services prescrits par les professionnels travaillant \u00e0 la clinique peuvent \u00e9galement \u00eatre disponibles dans d'autres lieux, et que je suis libre de choisir les services propos\u00e9s ici ou dans tout autre \u00e9tablissement de mon choix.\n                <\/li>\n            <\/ul>\n        <\/div>\n        <div class=\"not-sleep-section-terms\">\n            <ul>\n                <li> Je d\u00e9clare qu\u2019au meilleur de mes connaissances, les informations mentionn\u00e9es ci-dessus sont exactes et compl\u00e8tes. Je comprends qu\u2019une fausse d\u00e9claration pourrait mettre ma sant\u00e9 en danger.\n                <\/li>\n                <li>\n                    J'accepte <a id=\"privacy-policy-link-fr\" style=\"color:black\" href=\"#\">la politique de confidentialit\u00e9 du site Web<\/a> et la \n                    <a id=\"personal-info-policy-link-fr\" style=\"color:black\" href=\"#\">politique d'informations personnelles<\/a>.\n                <\/li>\n                <li> Je suis conscient que tous les vaccins et les m\u00e9dicaments discut\u00e9s durant la consultation sont des recommandations et non des obligations, \u00e0 moins d\u2019information contraire sur le site sant\u00e9-voyage du Gouvernement du Canada (ex: exigences d\u2019entr\u00e9e pour la fi\u00e8vre jaune).\n                <\/li>\n                <li> Je comprends que je suis responsable de toutes les informations n\u00e9cessaires pour l\u2019obtention de visa et d\u2019autres documents n\u00e9cessaires au voyage.\n                <\/li>\n                <li> Je suis conscient qu\u2019il est recommand\u00e9 de demeurer \u00e0 la clinique durant les 15 minutes suivant la vaccination.\n                <\/li>\n                <li> Je comprends que je suis responsable de la manipulation et l\u2019entreposage de tous les m\u00e9dicaments et\/ou vaccins achet\u00e9s pour usage ult\u00e9rieur (ex: Dukoral et Vivotif). Je comprends que ces vaccins doivent \u00eatre r\u00e9frig\u00e9r\u00e9s entre 2 et 8 degr\u00e9s Celsius.\n                <\/li>\n                <li> Je comprends que des frais de consultation et de vaccination s\u2019appliquent \u00e0 chaque visite. Je sais que ces frais sont payables le jour du rendez-vous et que tous les paiements doivent \u00eatre faits par carte (carte de cr\u00e9dit ou d\u00e9bit).\n                <\/li>\n                <li id=\"covidBullet\" style=\"display:none\">Je consens \u00e0 recevoir les r\u00e9sultats de mon test COVID-19 par courriel. Je confirme que les r\u00e9sultats du test doivent \u00eatre envoy\u00e9s \u00e0 l'adresse courriel indiqu\u00e9e ci-dessus.\n                <\/li>\n            <\/ul>\n            <div id=\"paladinBullet\" style=\"display:none\">\n                <hr>\n                <p>\n                <h4>S\u00e9curit\u00e9 Paladin<\/h4>\n                <ul>\n                    <input data-clarity-unmask=\"true\" class=\"form-check-input\" type=\"checkbox\" value=\"\"\n                           id=\"paladinCheckbox\">\n                    Je consens \u00e0 ce que Summit Sant\u00e9 partage mes dossiers m\u00e9dicaux et de vaccination avec l'organisation responsable du financement de mes services, conform\u00e9ment \u00e0 l'accord de partage de donn\u00e9es entre Summit Sant\u00e9 et l'organisation. Ce consentement est limit\u00e9 aux services sp\u00e9cifiques financ\u00e9s par l'organisation.\n                <\/ul>\n                <\/p>\n                <div class=\"mb-3\">\n                    <label class=\"form-label\" for=\"customFile\">Ajoutez votre dossier de vaccination<\/label>\n                    <br>\n                    <span>Veuillez prendre une photo ou t\u00e9l\u00e9charger un fichier avec votre dossier de vaccination existant afin de rendre votre rendez-vous aussi efficace que possible. Veuillez apporter votre dossier de vaccination lors de votre rendez-vous.<\/span>\n                    <input data-clarity-unmask=\"true\" type=\"file\" accept=\"application\/pdf,image\/*\" class=\"form-control\"\n                           id=\"immunizationRecordUpload\"\/>\n                <\/div>\n            <\/div>\n        <\/div>\n\n\n        <div class=\"form-check mt-3\">\n            <input class=\"form-check-input\" type=\"checkbox\" id=\"agreementCheckbox\" required>\n            <label class=\"form-check-label\" for=\"agreementCheckbox\">\n                J'accepte les termes et conditions ci-dessus\n            <\/label>\n            <div class=\"invalid-feedback\">\n                Vous devez accepter avant de soumettre.\n            <\/div>\n        <\/div>\n        <div class=\"mb-3\" style=\"margin-top:20px;\">\n            <button type=\"button\" id=\"submitBtnId\" class=\"btn btn-primary\">Soumettre<\/button>\n        <\/div>\n    <\/form>\n    <div id=\"loadingDiv\" class=\"row\" style=\"text-align:center; display:none\">\n        <div style=\"margin-bottom:20px\" class=\"fa-3x\"><i class=\"fas fa-spinner fa-pulse\"><\/i><\/div>\n        <p>Soumission du Questionnaire en cours ...<\/p>\n    <\/div>\n\n\n\n    <script>\n    \/\/ Get the current domain\n    const domain = window.location.hostname;\n    console.log(\"working with domain\" + domain)\n\n    \/\/ Build the dynamic URLs based on the current domain\n    const privacyPolicyUrlFr = `https:\/\/${domain}\/website-privacy-policy\/`;\n    const personalInfoPolicyUrlFr = `https:\/\/${domain}\/personal-information-policy\/`;\n\n    \/\/ Set the href attributes dynamically\n    document.getElementById('privacy-policy-link-fr').href = privacyPolicyUrlFr;\n    document.getElementById('personal-info-policy-link-fr').href = personalInfoPolicyUrlFr;\n    <\/script>\n\n<\/div>\n<\/body>\n<\/html>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Questionnaire Effacer &#038; resoumettre le questionnaire En tant que patient de Summit Sant\u00e9, nous avons le questionnaire m\u00e9dical rempli lors de votre derni\u00e8re visite. Je confirme qu&rsquo;il n&rsquo;y a eu aucun changement \u00e0 ma sant\u00e9 ou aux m\u00e9dicaments que je prends depuis ma derni\u00e8re visite chez Summit Sant\u00e9. Confirmer Remplir un nouveau questionnaire Information D\u00e9mographique &#8230; <a title=\"Questionnaire m\u00e9dical\" class=\"read-more\" href=\"https:\/\/dormalab.com\/fr\/questionnaire-medical\/\" aria-label=\"En savoir plus sur Questionnaire m\u00e9dical\">Lire la suite<\/a><\/p>\n","protected":false},"author":22,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-39137","page","type-page","status-publish"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Questionnaire m\u00e9dical - Dorma Sleep Clinics<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/dormalab.com\/fr\/questionnaire-medical\/\" \/>\n<meta property=\"og:locale\" content=\"fr_FR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Questionnaire m\u00e9dical - Dorma Sleep Clinics\" \/>\n<meta property=\"og:description\" content=\"Questionnaire Effacer &#038; resoumettre le questionnaire En tant que patient de Summit Sant\u00e9, nous avons le questionnaire m\u00e9dical rempli lors de votre derni\u00e8re visite. Je confirme qu&rsquo;il n&rsquo;y a eu aucun changement \u00e0 ma sant\u00e9 ou aux m\u00e9dicaments que je prends depuis ma derni\u00e8re visite chez Summit Sant\u00e9. Confirmer Remplir un nouveau questionnaire Information D\u00e9mographique ... 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