<?php
$contentData = false;
if($section){
    $contentData = json_decode($section->content_data, true);
}
if(!$contentData) {
    $contentData = [];
}
$formID = rand(0, 100000);
?>
<form method="POST" action="/process_form_submit" onsubmit="return submitForm_NoteSection_{{ $formID }}(this);">
    <?php if($section): ?>
        <input type="hidden" name="section_uid" value="<?= $section->uid?>">
    <?php else: ?>
        <input type="hidden" name="note_uid" value="<?= $note->uid?>">
        <input type="hidden" name="section_template_uid" value="<?= $sectionTemplate->uid ?>">
    <?php endif; ?>

    <div class="gem-nodes">
    <div class="my-3 node node-level-0" data-key="how_are_you">
        <div class="d-flex align-items-end">
            <label class="mb-0">How are you doing?</label>
            {{--<button class="btn btn-sm btn-primary ml-auto">Done</button>--}}
            <button type="button" class="btn btn-sm btn-primary ml-auto" onclick="return fastReload()">Done</button>
        </div>
        <div class="subs pl-4">
            <div class="my-3 node node-level-2" data-key="how_are_you__with_quarantine">
                <label>How are you doing with quarantine?</label>
                <div class="d-flex align-items-center">
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['how_are_you__with_quarantine'] }}" name="how_are_you__with_quarantine" type="text" class="form-control form-control-sm mr-2" placeholder="Answer">
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['how_are_you__with_quarantine_memo'] }}" name="how_are_you__with_quarantine_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                </div>
            </div>

            <div class="my-3 node node-level-2" data-key="how_are_you__with_health_in_general">
                <label>How are you doing with you health in general?</label>
                <div class="d-flex align-items-center">
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['how_are_you__with_health_in_general'] }}" name="how_are_you__with_health_in_general" type="text" class="form-control form-control-sm mr-2" placeholder="Answer">
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['how_are_you__with_health_in_general_memo'] }}" name="how_are_you__with_health_in_general_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                </div>
            </div>

        </div>
    </div>

    <div class="my-3 node node-level-0" data-key="blood_ox">
        <label>Blood Oxygen</label>
        <div class="subs pl-4">
            <div class="my-3 node node-level-2" data-key="blood_ox__ever_used_fingertip_meter">
                <label>Have you ever used a fingertip blood oxygen saturation meter before?</label>
                <div class="d-flex align-items-center">
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['blood_ox__ever_used_fingertip_meter'] === 'YES' ? 'checked' : '' }} name="blood_ox__ever_used_fingertip_meter" type="radio" value="YES" class="mr-1">
                        <span>Yes</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['blood_ox__ever_used_fingertip_meter'] === 'NO' ? 'checked' : '' }} name="blood_ox__ever_used_fingertip_meter" type="radio" value="NO" class="mr-1">
                        <span>No</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['blood_ox__ever_used_fingertip_meter'] === 'UNKNOWN' ? 'checked' : '' }} name="blood_ox__ever_used_fingertip_meter" type="radio" value="UNKNOWN" class="mr-1">
                        <span>Unknown</span>
                    </label>
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['blood_ox__ever_used_fingertip_meter_memo'] }}" name="blood_ox__ever_used_fingertip_meter_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                </div>
                <div class="subs pl-4">
                    <div class="my-3 node node-level-4" data-key="blood_ox__ever_used_fingertip_meter__has_one">
                        <label>Do you currently have one at home?</label>
                        <div class="d-flex align-items-center">
                            <label class="d-inline-flex align-items-center my-0 mr-3">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['blood_ox__ever_used_fingertip_meter__has_one'] === 'YES' ? 'checked' : '' }} name="blood_ox__ever_used_fingertip_meter__has_one" type="radio" value="YES" class="mr-1">
                                <span>Yes</span>
                            </label>
                            <label class="d-inline-flex align-items-center my-0 mr-3">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['blood_ox__ever_used_fingertip_meter__has_one'] === 'NO' ? 'checked' : '' }} name="blood_ox__ever_used_fingertip_meter__has_one" type="radio" value="NO" class="mr-1">
                                <span>No</span>
                            </label>
                            <label class="d-inline-flex align-items-center my-0 mr-3">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['blood_ox__ever_used_fingertip_meter__has_one'] === 'UNKNOWN' ? 'checked' : '' }} name="blood_ox__ever_used_fingertip_meter__has_one" type="radio" value="UNKNOWN" class="mr-1">
                                <span>Unknown</span>
                            </label>
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['blood_ox__ever_used_fingertip_meter__has_one_memo'] }}" name="blood_ox__ever_used_fingertip_meter__has_one_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                        </div>
                    </div>

                    <div class="my-3 node node-level-4" data-key="blood_ox__ever_used_fingertip_meter__confirmed_will_discontinue_current">
                        <label>If yes, can you please discontinue use of that when you receive the one we send you?</label>
                        <div class="d-flex align-items-center">
                            <label class="d-inline-flex align-items-center my-0 mr-3">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['blood_ox__ever_used_fingertip_meter__confirmed_will_discontinue_current'] === 'YES' ? 'checked' : '' }} name="blood_ox__ever_used_fingertip_meter__confirmed_will_discontinue_current" type="radio" value="YES" class="mr-1">
                                <span>Yes</span>
                            </label>
                            <label class="d-inline-flex align-items-center my-0 mr-3">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['blood_ox__ever_used_fingertip_meter__confirmed_will_discontinue_current'] === 'NO' ? 'checked' : '' }} name="blood_ox__ever_used_fingertip_meter__confirmed_will_discontinue_current" type="radio" value="NO" class="mr-1">
                                <span>No</span>
                            </label>
                            <label class="d-inline-flex align-items-center my-0 mr-3">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['blood_ox__ever_used_fingertip_meter__confirmed_will_discontinue_current'] === 'UNKNOWN' ? 'checked' : '' }} name="blood_ox__ever_used_fingertip_meter__confirmed_will_discontinue_current" type="radio" value="UNKNOWN" class="mr-1">
                                <span>Unknown</span>
                            </label>
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['blood_ox__ever_used_fingertip_meter__confirmed_will_discontinue_current_memo'] }}" name="blood_ox__ever_used_fingertip_meter__confirmed_will_discontinue_current_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                        </div>
                    </div>

                </div>
            </div>

            <div class="my-3 node node-level-2" data-key="blood_ox__does_pcp_regularly_check">
                <label>Does your PCP regularly check your resting oxygen saturation?</label>
                <div class="d-flex align-items-center">
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['blood_ox__does_pcp_regularly_check'] === 'YES' ? 'checked' : '' }} name="blood_ox__does_pcp_regularly_check" type="radio" value="YES" class="mr-1">
                        <span>Yes</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['blood_ox__does_pcp_regularly_check'] === 'NO' ? 'checked' : '' }} name="blood_ox__does_pcp_regularly_check" type="radio" value="NO" class="mr-1">
                        <span>No</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['blood_ox__does_pcp_regularly_check'] === 'UNKNOWN' ? 'checked' : '' }} name="blood_ox__does_pcp_regularly_check" type="radio" value="UNKNOWN" class="mr-1">
                        <span>Unknown</span>
                    </label>
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['blood_ox__does_pcp_regularly_check_memo'] }}" name="blood_ox__does_pcp_regularly_check_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                </div>
            </div>

            <div class="my-3 node node-level-2" data-key="blood_ox__baseline_resting_spo2_level">
                <label>Do you know what your baseline resting oxygen saturation usually measures at?</label>
                <div class="d-flex align-items-center">
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['blood_ox__baseline_resting_spo2_level'] }}" name="blood_ox__baseline_resting_spo2_level" type="text" class="form-control form-control-sm" placeholder="Answer">
                    <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['blood_ox__baseline_resting_spo2_level_unknown'] ? 'checked' : '' }} name="blood_ox__baseline_resting_spo2_level_unknown" type="checkbox" class="mr-1">
                        <span>Unknown</span>
                    </label>
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['blood_ox__baseline_resting_spo2_level_memo'] }}" name="blood_ox__baseline_resting_spo2_level_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                </div>
            </div>

            <div class="my-3 node node-level-2" data-key="blood_ox__lung_condition_that_may_affect">
                <label>Do you have any lung condition, such as asthma or COPD, that might affect the reading when you measure your blood oxygen level?</label>
                <div class="d-flex align-items-center">
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['blood_ox__lung_condition_that_may_affect'] === 'YES' ? 'checked' : '' }} name="blood_ox__lung_condition_that_may_affect" type="radio" value="YES" class="mr-1">
                        <span>Yes</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['blood_ox__lung_condition_that_may_affect'] === 'NO' ? 'checked' : '' }} name="blood_ox__lung_condition_that_may_affect" type="radio" value="NO" class="mr-1">
                        <span>No</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['blood_ox__lung_condition_that_may_affect'] === 'UNKNOWN' ? 'checked' : '' }} name="blood_ox__lung_condition_that_may_affect" type="radio" value="UNKNOWN" class="mr-1">
                        <span>Unknown</span>
                    </label>
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['blood_ox__lung_condition_that_may_affect_memo'] }}" name="blood_ox__lung_condition_that_may_affect_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                </div>
            </div>

            <div class="my-3 node node-level-2" data-key="blood_ox__o2_and_activity">
                <label>Blood oxygen values depend a lot on your level of physical activity.</label>
                <div class="subs pl-4">
                    <div class="my-3 node node-level-4" data-key="blood_ox__o2_and_activity__days_per_week_aerobic_exercise_with_exertion">
                        <label>How many days per week do you currently perform aerobic exercise to the point that you can feel your lungs working harder and your heart beating faster?</label>
                        <div class="d-flex align-items-center">
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['blood_ox__o2_and_activity__days_per_week_aerobic_exercise_with_exertion'] }}" name="blood_ox__o2_and_activity__days_per_week_aerobic_exercise_with_exertion" type="text" class="form-control form-control-sm mr-2" placeholder="Answer">
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['blood_ox__o2_and_activity__days_per_week_aerobic_exercise_with_exertion_memo'] }}" name="blood_ox__o2_and_activity__days_per_week_aerobic_exercise_with_exertion_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                        </div>
                    </div>

                    <div class="my-3 node node-level-4" data-key="blood_ox__o2_and_activity__minutes_per_week_aerobic_exercise_with_exertion">
                        <label>How many total minutes per week on average would you say you are in a state of aerobic exercise, where you feel your lungs working harder and your heart beating faster?</label>
                        <div class="d-flex align-items-center">
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['blood_ox__o2_and_activity__minutes_per_week_aerobic_exercise_with_exertion'] }}" name="blood_ox__o2_and_activity__minutes_per_week_aerobic_exercise_with_exertion" type="text" class="form-control form-control-sm mr-2" placeholder="Answer">
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['blood_ox__o2_and_activity__minutes_per_week_aerobic_exercise_with_exertion_memo'] }}" name="blood_ox__o2_and_activity__minutes_per_week_aerobic_exercise_with_exertion_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                        </div>
                    </div>

                    <div class="my-3 node node-level-4" data-key="blood_ox__o2_and_activity__ever_had_o2_checked_before_after_exercise">
                        <label>Have you ever had your oxygen checked before and after exercise?</label>
                        <div class="d-flex align-items-center">
                            <label class="d-inline-flex align-items-center my-0 mr-3">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['blood_ox__o2_and_activity__ever_had_o2_checked_before_after_exercise'] === 'YES' ? 'checked' : '' }} name="blood_ox__o2_and_activity__ever_had_o2_checked_before_after_exercise" type="radio" value="YES" class="mr-1">
                                <span>Yes</span>
                            </label>
                            <label class="d-inline-flex align-items-center my-0 mr-3">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['blood_ox__o2_and_activity__ever_had_o2_checked_before_after_exercise'] === 'NO' ? 'checked' : '' }} name="blood_ox__o2_and_activity__ever_had_o2_checked_before_after_exercise" type="radio" value="NO" class="mr-1">
                                <span>No</span>
                            </label>
                            <label class="d-inline-flex align-items-center my-0 mr-3">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['blood_ox__o2_and_activity__ever_had_o2_checked_before_after_exercise'] === 'UNKNOWN' ? 'checked' : '' }} name="blood_ox__o2_and_activity__ever_had_o2_checked_before_after_exercise" type="radio" value="UNKNOWN" class="mr-1">
                                <span>Unknown</span>
                            </label>
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['blood_ox__o2_and_activity__ever_had_o2_checked_before_after_exercise_memo'] }}" name="blood_ox__o2_and_activity__ever_had_o2_checked_before_after_exercise_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                        </div>
                    </div>

                    <div class="my-3 node node-level-4" data-key="blood_ox__o2_and_activity__baseline_o2_assessment">
                        <label>Once you receive the oxygen meter, our nurse will need to call you to make sure you take a proper baseline resting measurement, and then another measurement after you walk at a normal speed for 1 minute. When is the best time and number to call usually?</label>
                        <div class="d-flex align-items-center">
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['blood_ox__o2_and_activity__baseline_o2_assessment'] }}" name="blood_ox__o2_and_activity__baseline_o2_assessment" type="text" class="form-control form-control-sm mr-2" placeholder="Answer">
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['blood_ox__o2_and_activity__baseline_o2_assessment_memo'] }}" name="blood_ox__o2_and_activity__baseline_o2_assessment_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                        </div>
                        <div class="subs pl-4">
                            <div class="my-3 node node-level-6" data-key="blood_ox__o2_and_activity__baseline_o2_assessment__best_time_to_call">
                                <label>Best time to call:</label>
                                <div class="d-flex align-items-center">
                                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['blood_ox__o2_and_activity__baseline_o2_assessment__best_time_to_call'] }}" name="blood_ox__o2_and_activity__baseline_o2_assessment__best_time_to_call" type="text" class="form-control form-control-sm mr-2" placeholder="Answer">
                                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['blood_ox__o2_and_activity__baseline_o2_assessment__best_time_to_call_memo'] }}" name="blood_ox__o2_and_activity__baseline_o2_assessment__best_time_to_call_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                                </div>
                            </div>

                            <div class="my-3 node node-level-6" data-key="blood_ox__o2_and_activity__baseline_o2_assessment__best_number_to_call">
                                <label>Best number to call:</label>
                                <div class="d-flex align-items-center">
                                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['blood_ox__o2_and_activity__baseline_o2_assessment__best_number_to_call'] }}" name="blood_ox__o2_and_activity__baseline_o2_assessment__best_number_to_call" type="text" class="form-control form-control-sm mr-2" placeholder="Answer">
                                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['blood_ox__o2_and_activity__baseline_o2_assessment__best_number_to_call_memo'] }}" name="blood_ox__o2_and_activity__baseline_o2_assessment__best_number_to_call_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                                </div>
                            </div>

                        </div>
                    </div>

                    <div class="my-3 node node-level-4" data-key="blood_ox__o2_and_activity__has_covid_made_you_less_physically_active">
                        <label>Has the COVID-19 pandemic made you less physically active than you were before?</label>
                        <div class="d-flex align-items-center">
                            <label class="d-inline-flex align-items-center my-0 mr-3">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['blood_ox__o2_and_activity__has_covid_made_you_less_physically_active'] === 'YES' ? 'checked' : '' }} name="blood_ox__o2_and_activity__has_covid_made_you_less_physically_active" type="radio" value="YES" class="mr-1">
                                <span>Yes</span>
                            </label>
                            <label class="d-inline-flex align-items-center my-0 mr-3">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['blood_ox__o2_and_activity__has_covid_made_you_less_physically_active'] === 'NO' ? 'checked' : '' }} name="blood_ox__o2_and_activity__has_covid_made_you_less_physically_active" type="radio" value="NO" class="mr-1">
                                <span>No</span>
                            </label>
                            <label class="d-inline-flex align-items-center my-0 mr-3">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['blood_ox__o2_and_activity__has_covid_made_you_less_physically_active'] === 'UNKNOWN' ? 'checked' : '' }} name="blood_ox__o2_and_activity__has_covid_made_you_less_physically_active" type="radio" value="UNKNOWN" class="mr-1">
                                <span>Unknown</span>
                            </label>
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['blood_ox__o2_and_activity__has_covid_made_you_less_physically_active_memo'] }}" name="blood_ox__o2_and_activity__has_covid_made_you_less_physically_active_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                        </div>
                    </div>

                </div>
            </div>

        </div>
    </div>

    <div class="my-3 node node-level-0" data-key="pulse_and_bp">
        <label>Pulse & BP</label>
        <div class="subs pl-4">
            <div class="my-3 node node-level-2" data-key="pulse_and_bp__ever_used_auto_pulse_bp_meter">
                <label>Have you ever used an automatic pulse and blood pressure meter before?</label>
                <div class="d-flex align-items-center">
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['pulse_and_bp__ever_used_auto_pulse_bp_meter'] === 'YES' ? 'checked' : '' }} name="pulse_and_bp__ever_used_auto_pulse_bp_meter" type="radio" value="YES" class="mr-1">
                        <span>Yes</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['pulse_and_bp__ever_used_auto_pulse_bp_meter'] === 'NO' ? 'checked' : '' }} name="pulse_and_bp__ever_used_auto_pulse_bp_meter" type="radio" value="NO" class="mr-1">
                        <span>No</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['pulse_and_bp__ever_used_auto_pulse_bp_meter'] === 'UNKNOWN' ? 'checked' : '' }} name="pulse_and_bp__ever_used_auto_pulse_bp_meter" type="radio" value="UNKNOWN" class="mr-1">
                        <span>Unknown</span>
                    </label>
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['pulse_and_bp__ever_used_auto_pulse_bp_meter_memo'] }}" name="pulse_and_bp__ever_used_auto_pulse_bp_meter_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                </div>
                <div class="subs pl-4">
                    <div class="my-3 node node-level-4" data-key="pulse_and_bp__ever_used_auto_pulse_bp_meter__has_one">
                        <label>Do you currently have one at home?</label>
                        <div class="d-flex align-items-center">
                            <label class="d-inline-flex align-items-center my-0 mr-3">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['pulse_and_bp__ever_used_auto_pulse_bp_meter__has_one'] === 'YES' ? 'checked' : '' }} name="pulse_and_bp__ever_used_auto_pulse_bp_meter__has_one" type="radio" value="YES" class="mr-1">
                                <span>Yes</span>
                            </label>
                            <label class="d-inline-flex align-items-center my-0 mr-3">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['pulse_and_bp__ever_used_auto_pulse_bp_meter__has_one'] === 'NO' ? 'checked' : '' }} name="pulse_and_bp__ever_used_auto_pulse_bp_meter__has_one" type="radio" value="NO" class="mr-1">
                                <span>No</span>
                            </label>
                            <label class="d-inline-flex align-items-center my-0 mr-3">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['pulse_and_bp__ever_used_auto_pulse_bp_meter__has_one'] === 'UNKNOWN' ? 'checked' : '' }} name="pulse_and_bp__ever_used_auto_pulse_bp_meter__has_one" type="radio" value="UNKNOWN" class="mr-1">
                                <span>Unknown</span>
                            </label>
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['pulse_and_bp__ever_used_auto_pulse_bp_meter__has_one_memo'] }}" name="pulse_and_bp__ever_used_auto_pulse_bp_meter__has_one_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                        </div>
                    </div>

                    <div class="my-3 node node-level-4" data-key="pulse_and_bp__ever_used_auto_pulse_bp_meter__confirmed_will_discontinue_current">
                        <label>If yes, can you please discontinue use of that when you receive the one we send you?</label>
                        <div class="d-flex align-items-center">
                            <label class="d-inline-flex align-items-center my-0 mr-3">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['pulse_and_bp__ever_used_auto_pulse_bp_meter__confirmed_will_discontinue_current'] === 'YES' ? 'checked' : '' }} name="pulse_and_bp__ever_used_auto_pulse_bp_meter__confirmed_will_discontinue_current" type="radio" value="YES" class="mr-1">
                                <span>Yes</span>
                            </label>
                            <label class="d-inline-flex align-items-center my-0 mr-3">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['pulse_and_bp__ever_used_auto_pulse_bp_meter__confirmed_will_discontinue_current'] === 'NO' ? 'checked' : '' }} name="pulse_and_bp__ever_used_auto_pulse_bp_meter__confirmed_will_discontinue_current" type="radio" value="NO" class="mr-1">
                                <span>No</span>
                            </label>
                            <label class="d-inline-flex align-items-center my-0 mr-3">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['pulse_and_bp__ever_used_auto_pulse_bp_meter__confirmed_will_discontinue_current'] === 'UNKNOWN' ? 'checked' : '' }} name="pulse_and_bp__ever_used_auto_pulse_bp_meter__confirmed_will_discontinue_current" type="radio" value="UNKNOWN" class="mr-1">
                                <span>Unknown</span>
                            </label>
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['pulse_and_bp__ever_used_auto_pulse_bp_meter__confirmed_will_discontinue_current_memo'] }}" name="pulse_and_bp__ever_used_auto_pulse_bp_meter__confirmed_will_discontinue_current_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                        </div>
                    </div>

                </div>
            </div>

            <div class="my-3 node node-level-2" data-key="pulse_and_bp__usual_resting_pulse">
                <label>What is your usual resting pulse?</label>
                <div class="d-flex align-items-center">
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['pulse_and_bp__usual_resting_pulse'] }}" name="pulse_and_bp__usual_resting_pulse" type="text" class="form-control form-control-sm" placeholder="Answer">
                    <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['pulse_and_bp__usual_resting_pulse_unknown'] ? 'checked' : '' }} name="pulse_and_bp__usual_resting_pulse_unknown" type="checkbox" class="mr-1">
                        <span>Unknown</span>
                    </label>
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['pulse_and_bp__usual_resting_pulse_memo'] }}" name="pulse_and_bp__usual_resting_pulse_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                </div>
            </div>

            <div class="my-3 node node-level-2" data-key="pulse_and_bp__usual_resting_bp">
                <label>What is your usual resting blood pressure?</label>
                <div class="subs pl-4">
                    <div class="my-3 node node-level-4" data-key="pulse_and_bp__usual_resting_bp__systolic">
                        <label>Systolic</label>
                        <div class="d-flex align-items-center">
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['pulse_and_bp__usual_resting_bp__systolic'] }}" name="pulse_and_bp__usual_resting_bp__systolic" type="text" class="form-control form-control-sm" placeholder="Answer">
                            <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['pulse_and_bp__usual_resting_bp__systolic_unknown'] ? 'checked' : '' }} name="pulse_and_bp__usual_resting_bp__systolic_unknown" type="checkbox" class="mr-1">
                                <span>Unknown</span>
                            </label>
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['pulse_and_bp__usual_resting_bp__systolic_memo'] }}" name="pulse_and_bp__usual_resting_bp__systolic_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                        </div>
                    </div>

                    <div class="my-3 node node-level-4" data-key="pulse_and_bp__usual_resting_bp__diastolic">
                        <label>Diastolic</label>
                        <div class="d-flex align-items-center">
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['pulse_and_bp__usual_resting_bp__diastolic'] }}" name="pulse_and_bp__usual_resting_bp__diastolic" type="text" class="form-control form-control-sm" placeholder="Answer">
                            <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['pulse_and_bp__usual_resting_bp__diastolic_unknown'] ? 'checked' : '' }} name="pulse_and_bp__usual_resting_bp__diastolic_unknown" type="checkbox" class="mr-1">
                                <span>Unknown</span>
                            </label>
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['pulse_and_bp__usual_resting_bp__diastolic_memo'] }}" name="pulse_and_bp__usual_resting_bp__diastolic_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                        </div>
                    </div>

                </div>
            </div>

            <div class="my-3 node node-level-2" data-key="pulse_and_bp__ever_dx_with_htn">
                <label>Have you ever been diagnosed with high blood pressure?</label>
                <div class="d-flex align-items-center">
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['pulse_and_bp__ever_dx_with_htn'] === 'YES' ? 'checked' : '' }} name="pulse_and_bp__ever_dx_with_htn" type="radio" value="YES" class="mr-1">
                        <span>Yes</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['pulse_and_bp__ever_dx_with_htn'] === 'NO' ? 'checked' : '' }} name="pulse_and_bp__ever_dx_with_htn" type="radio" value="NO" class="mr-1">
                        <span>No</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['pulse_and_bp__ever_dx_with_htn'] === 'UNKNOWN' ? 'checked' : '' }} name="pulse_and_bp__ever_dx_with_htn" type="radio" value="UNKNOWN" class="mr-1">
                        <span>Unknown</span>
                    </label>
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['pulse_and_bp__ever_dx_with_htn_memo'] }}" name="pulse_and_bp__ever_dx_with_htn_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                </div>
                <div class="subs pl-4">
                    <div class="my-3 node node-level-4" data-key="pulse_and_bp__ever_dx_with_htn__on_bp_medications">
                        <label>Are you on any BP medication?</label>
                        <div class="d-flex align-items-center">
                            <label class="d-inline-flex align-items-center my-0 mr-3">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['pulse_and_bp__ever_dx_with_htn__on_bp_medications'] === 'YES' ? 'checked' : '' }} name="pulse_and_bp__ever_dx_with_htn__on_bp_medications" type="radio" value="YES" class="mr-1">
                                <span>Yes</span>
                            </label>
                            <label class="d-inline-flex align-items-center my-0 mr-3">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['pulse_and_bp__ever_dx_with_htn__on_bp_medications'] === 'NO' ? 'checked' : '' }} name="pulse_and_bp__ever_dx_with_htn__on_bp_medications" type="radio" value="NO" class="mr-1">
                                <span>No</span>
                            </label>
                            <label class="d-inline-flex align-items-center my-0 mr-3">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['pulse_and_bp__ever_dx_with_htn__on_bp_medications'] === 'UNKNOWN' ? 'checked' : '' }} name="pulse_and_bp__ever_dx_with_htn__on_bp_medications" type="radio" value="UNKNOWN" class="mr-1">
                                <span>Unknown</span>
                            </label>
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['pulse_and_bp__ever_dx_with_htn__on_bp_medications_memo'] }}" name="pulse_and_bp__ever_dx_with_htn__on_bp_medications_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                        </div>
                    </div>

                    <div class="my-3 node node-level-4" data-key="pulse_and_bp__ever_dx_with_htn__who_treats">
                        <label>Who primarily treats your HTN?</label>
                        <div class="d-flex align-items-center">
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['pulse_and_bp__ever_dx_with_htn__who_treats'] }}" name="pulse_and_bp__ever_dx_with_htn__who_treats" type="text" class="form-control form-control-sm" placeholder="Answer">
                            <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['pulse_and_bp__ever_dx_with_htn__who_treats_unknown'] ? 'checked' : '' }} name="pulse_and_bp__ever_dx_with_htn__who_treats_unknown" type="checkbox" class="mr-1">
                                <span>Unknown</span>
                            </label>
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['pulse_and_bp__ever_dx_with_htn__who_treats_memo'] }}" name="pulse_and_bp__ever_dx_with_htn__who_treats_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                        </div>
                    </div>

                </div>
            </div>

            <div class="my-3 node node-level-2" data-key="pulse_and_bp__pcp_or_other_doc_bp_target">
                <label>Has your primary care physician, or another doctor, ever told you what your target BP should be?</label>
                <div class="d-flex align-items-center">
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['pulse_and_bp__pcp_or_other_doc_bp_target'] }}" name="pulse_and_bp__pcp_or_other_doc_bp_target" type="text" class="form-control form-control-sm" placeholder="Answer">
                    <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['pulse_and_bp__pcp_or_other_doc_bp_target_unknown'] ? 'checked' : '' }} name="pulse_and_bp__pcp_or_other_doc_bp_target_unknown" type="checkbox" class="mr-1">
                        <span>Unknown</span>
                    </label>
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['pulse_and_bp__pcp_or_other_doc_bp_target_memo'] }}" name="pulse_and_bp__pcp_or_other_doc_bp_target_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                </div>
                <div class="subs pl-4">
                    <div class="my-3 node node-level-4" data-key="pulse_and_bp__pcp_or_other_doc_bp_target__systolic">
                        <label>Systolic</label>
                        <div class="d-flex align-items-center">
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['pulse_and_bp__pcp_or_other_doc_bp_target__systolic'] }}" name="pulse_and_bp__pcp_or_other_doc_bp_target__systolic" type="text" class="form-control form-control-sm" placeholder="Answer">
                            <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['pulse_and_bp__pcp_or_other_doc_bp_target__systolic_unknown'] ? 'checked' : '' }} name="pulse_and_bp__pcp_or_other_doc_bp_target__systolic_unknown" type="checkbox" class="mr-1">
                                <span>Unknown</span>
                            </label>
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['pulse_and_bp__pcp_or_other_doc_bp_target__systolic_memo'] }}" name="pulse_and_bp__pcp_or_other_doc_bp_target__systolic_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                        </div>
                    </div>

                    <div class="my-3 node node-level-4" data-key="pulse_and_bp__pcp_or_other_doc_bp_target__diastolic">
                        <label>Diastolic</label>
                        <div class="d-flex align-items-center">
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['pulse_and_bp__pcp_or_other_doc_bp_target__diastolic'] }}" name="pulse_and_bp__pcp_or_other_doc_bp_target__diastolic" type="text" class="form-control form-control-sm" placeholder="Answer">
                            <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['pulse_and_bp__pcp_or_other_doc_bp_target__diastolic_unknown'] ? 'checked' : '' }} name="pulse_and_bp__pcp_or_other_doc_bp_target__diastolic_unknown" type="checkbox" class="mr-1">
                                <span>Unknown</span>
                            </label>
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['pulse_and_bp__pcp_or_other_doc_bp_target__diastolic_memo'] }}" name="pulse_and_bp__pcp_or_other_doc_bp_target__diastolic_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                        </div>
                    </div>

                </div>
            </div>

            <div class="my-3 node node-level-2" data-key="pulse_and_bp__pulse_during_exercise">
                <label>When you exercise, what does your pulse reach?</label>
                <div class="d-flex align-items-center">
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['pulse_and_bp__pulse_during_exercise'] }}" name="pulse_and_bp__pulse_during_exercise" type="text" class="form-control form-control-sm" placeholder="Answer">
                    <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['pulse_and_bp__pulse_during_exercise_unknown'] ? 'checked' : '' }} name="pulse_and_bp__pulse_during_exercise_unknown" type="checkbox" class="mr-1">
                        <span>Unknown</span>
                    </label>
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['pulse_and_bp__pulse_during_exercise_memo'] }}" name="pulse_and_bp__pulse_during_exercise_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                </div>
            </div>

        </div>
    </div>

    <div class="my-3 node node-level-0" data-key="temp_thermometer">
        <label>Thermometer / Temp.</label>
        <div class="subs pl-4">
            <div class="my-3 node node-level-2" data-key="temp_thermometer__ever_used_itg_before">
                <label>Have you ever used an infrared temperature gun before?</label>
                <div class="d-flex align-items-center">
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['temp_thermometer__ever_used_itg_before'] === 'YES' ? 'checked' : '' }} name="temp_thermometer__ever_used_itg_before" type="radio" value="YES" class="mr-1">
                        <span>Yes</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['temp_thermometer__ever_used_itg_before'] === 'NO' ? 'checked' : '' }} name="temp_thermometer__ever_used_itg_before" type="radio" value="NO" class="mr-1">
                        <span>No</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['temp_thermometer__ever_used_itg_before'] === 'UNKNOWN' ? 'checked' : '' }} name="temp_thermometer__ever_used_itg_before" type="radio" value="UNKNOWN" class="mr-1">
                        <span>Unknown</span>
                    </label>
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['temp_thermometer__ever_used_itg_before_memo'] }}" name="temp_thermometer__ever_used_itg_before_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                </div>
            </div>

            <div class="my-3 node node-level-2" data-key="temp_thermometer__usual_resting_temp">
                <label>What does your resting temperature usually run at?</label>
                <div class="d-flex align-items-center">
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['temp_thermometer__usual_resting_temp'] === 'YES' ? 'checked' : '' }} name="temp_thermometer__usual_resting_temp" type="radio" value="YES" class="mr-1">
                        <span>Yes</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['temp_thermometer__usual_resting_temp'] === 'NO' ? 'checked' : '' }} name="temp_thermometer__usual_resting_temp" type="radio" value="NO" class="mr-1">
                        <span>No</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['temp_thermometer__usual_resting_temp'] === 'UNKNOWN' ? 'checked' : '' }} name="temp_thermometer__usual_resting_temp" type="radio" value="UNKNOWN" class="mr-1">
                        <span>Unknown</span>
                    </label>
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['temp_thermometer__usual_resting_temp_memo'] }}" name="temp_thermometer__usual_resting_temp_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                </div>
            </div>

            <div class="my-3 node node-level-2" data-key="temp_thermometer__do_you_or_someone_at_home_go_outdoors">
                <label>Do you or anyone you live with currently go outdoors in public places?</label>
                <div class="d-flex align-items-center">
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['temp_thermometer__do_you_or_someone_at_home_go_outdoors'] === 'YES' ? 'checked' : '' }} name="temp_thermometer__do_you_or_someone_at_home_go_outdoors" type="radio" value="YES" class="mr-1">
                        <span>Yes</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['temp_thermometer__do_you_or_someone_at_home_go_outdoors'] === 'NO' ? 'checked' : '' }} name="temp_thermometer__do_you_or_someone_at_home_go_outdoors" type="radio" value="NO" class="mr-1">
                        <span>No</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['temp_thermometer__do_you_or_someone_at_home_go_outdoors'] === 'UNKNOWN' ? 'checked' : '' }} name="temp_thermometer__do_you_or_someone_at_home_go_outdoors" type="radio" value="UNKNOWN" class="mr-1">
                        <span>Unknown</span>
                    </label>
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['temp_thermometer__do_you_or_someone_at_home_go_outdoors_memo'] }}" name="temp_thermometer__do_you_or_someone_at_home_go_outdoors_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                </div>
            </div>

            <div class="my-3 node node-level-2" data-key="temp_thermometer__will_you_check_people_temp_before_they_come_near">
                <label>Can you start to check people's temperature before they come near you?</label>
                <div class="d-flex align-items-center">
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['temp_thermometer__will_you_check_people_temp_before_they_come_near'] === 'YES' ? 'checked' : '' }} name="temp_thermometer__will_you_check_people_temp_before_they_come_near" type="radio" value="YES" class="mr-1">
                        <span>Yes</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['temp_thermometer__will_you_check_people_temp_before_they_come_near'] === 'NO' ? 'checked' : '' }} name="temp_thermometer__will_you_check_people_temp_before_they_come_near" type="radio" value="NO" class="mr-1">
                        <span>No</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['temp_thermometer__will_you_check_people_temp_before_they_come_near'] === 'UNKNOWN' ? 'checked' : '' }} name="temp_thermometer__will_you_check_people_temp_before_they_come_near" type="radio" value="UNKNOWN" class="mr-1">
                        <span>Unknown</span>
                    </label>
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['temp_thermometer__will_you_check_people_temp_before_they_come_near_memo'] }}" name="temp_thermometer__will_you_check_people_temp_before_they_come_near_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                </div>
            </div>

        </div>
    </div>

    <div class="my-3 node node-level-0" data-key="bmi">
        <label>BMI</label>
        <div class="subs pl-4">
            <div class="my-3 node node-level-2" data-key="bmi__has_one">
                <label>Do you currently have one at home?</label>
                <div class="d-flex align-items-center">
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['bmi__has_one'] === 'YES' ? 'checked' : '' }} name="bmi__has_one" type="radio" value="YES" class="mr-1">
                        <span>Yes</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['bmi__has_one'] === 'NO' ? 'checked' : '' }} name="bmi__has_one" type="radio" value="NO" class="mr-1">
                        <span>No</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['bmi__has_one'] === 'UNKNOWN' ? 'checked' : '' }} name="bmi__has_one" type="radio" value="UNKNOWN" class="mr-1">
                        <span>Unknown</span>
                    </label>
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['bmi__has_one_memo'] }}" name="bmi__has_one_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                </div>
                <div class="subs pl-4">
                    <div class="my-3 node node-level-4" data-key="bmi__has_one__confirmed_will_discontinue_current">
                        <label>If yes, can you please discontinue use of that when you receive the one we send you?</label>
                        <div class="d-flex align-items-center">
                            <label class="d-inline-flex align-items-center my-0 mr-3">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['bmi__has_one__confirmed_will_discontinue_current'] === 'YES' ? 'checked' : '' }} name="bmi__has_one__confirmed_will_discontinue_current" type="radio" value="YES" class="mr-1">
                                <span>Yes</span>
                            </label>
                            <label class="d-inline-flex align-items-center my-0 mr-3">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['bmi__has_one__confirmed_will_discontinue_current'] === 'NO' ? 'checked' : '' }} name="bmi__has_one__confirmed_will_discontinue_current" type="radio" value="NO" class="mr-1">
                                <span>No</span>
                            </label>
                            <label class="d-inline-flex align-items-center my-0 mr-3">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['bmi__has_one__confirmed_will_discontinue_current'] === 'UNKNOWN' ? 'checked' : '' }} name="bmi__has_one__confirmed_will_discontinue_current" type="radio" value="UNKNOWN" class="mr-1">
                                <span>Unknown</span>
                            </label>
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['bmi__has_one__confirmed_will_discontinue_current_memo'] }}" name="bmi__has_one__confirmed_will_discontinue_current_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                        </div>
                    </div>

                </div>
            </div>

            <div class="my-3 node node-level-2" data-key="bmi__current">
                <label>What is your current:</label>
                <div class="subs pl-4">
                    <div class="my-3 node node-level-4" data-key="bmi__current__height_in_inches">
                        <label>Height in inches?</label>
                        <div class="d-flex align-items-center">
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['bmi__current__height_in_inches'] }}" name="bmi__current__height_in_inches" type="text" class="form-control form-control-sm" placeholder="Answer">
                            <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['bmi__current__height_in_inches_unknown'] ? 'checked' : '' }} name="bmi__current__height_in_inches_unknown" type="checkbox" class="mr-1">
                                <span>Unknown</span>
                            </label>
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['bmi__current__height_in_inches_memo'] }}" name="bmi__current__height_in_inches_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                        </div>
                    </div>

                    <div class="my-3 node node-level-4" data-key="bmi__current__weight_in_pounds">
                        <label>Weight in pounds?</label>
                        <div class="d-flex align-items-center">
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['bmi__current__weight_in_pounds'] }}" name="bmi__current__weight_in_pounds" type="text" class="form-control form-control-sm" placeholder="Answer">
                            <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['bmi__current__weight_in_pounds_unknown'] ? 'checked' : '' }} name="bmi__current__weight_in_pounds_unknown" type="checkbox" class="mr-1">
                                <span>Unknown</span>
                            </label>
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['bmi__current__weight_in_pounds_memo'] }}" name="bmi__current__weight_in_pounds_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                        </div>
                    </div>

                    <div class="my-3 node node-level-4" data-key="bmi__current__waistline_in_inches">
                        <label>Waistline in inches?</label>
                        <div class="d-flex align-items-center">
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['bmi__current__waistline_in_inches'] }}" name="bmi__current__waistline_in_inches" type="text" class="form-control form-control-sm" placeholder="Answer">
                            <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['bmi__current__waistline_in_inches_unknown'] ? 'checked' : '' }} name="bmi__current__waistline_in_inches_unknown" type="checkbox" class="mr-1">
                                <span>Unknown</span>
                            </label>
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['bmi__current__waistline_in_inches_memo'] }}" name="bmi__current__waistline_in_inches_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                        </div>
                    </div>

                    <div class="my-3 node node-level-4" data-key="bmi__current__body_fat_percent">
                        <label>Body fat %?</label>
                        <div class="d-flex align-items-center">
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['bmi__current__body_fat_percent'] }}" name="bmi__current__body_fat_percent" type="text" class="form-control form-control-sm" placeholder="Answer">
                            <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['bmi__current__body_fat_percent_unknown'] ? 'checked' : '' }} name="bmi__current__body_fat_percent_unknown" type="checkbox" class="mr-1">
                                <span>Unknown</span>
                            </label>
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['bmi__current__body_fat_percent_memo'] }}" name="bmi__current__body_fat_percent_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                        </div>
                    </div>

                </div>
            </div>

            <div class="my-3 node node-level-2" data-key="bmi__at_20_years_old">
                <label>When you were 20 years old, what was your:</label>
                <div class="subs pl-4">
                    <div class="my-3 node node-level-4" data-key="bmi__at_20_years_old__weight_in_pounds">
                        <label>Weight in pounds?</label>
                        <div class="d-flex align-items-center">
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['bmi__at_20_years_old__weight_in_pounds'] }}" name="bmi__at_20_years_old__weight_in_pounds" type="text" class="form-control form-control-sm" placeholder="Answer">
                            <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['bmi__at_20_years_old__weight_in_pounds_unknown'] ? 'checked' : '' }} name="bmi__at_20_years_old__weight_in_pounds_unknown" type="checkbox" class="mr-1">
                                <span>Unknown</span>
                            </label>
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['bmi__at_20_years_old__weight_in_pounds_memo'] }}" name="bmi__at_20_years_old__weight_in_pounds_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                        </div>
                    </div>

                    <div class="my-3 node node-level-4" data-key="bmi__at_20_years_old__waistline_in_inches">
                        <label>Waistline in inches?</label>
                        <div class="d-flex align-items-center">
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['bmi__at_20_years_old__waistline_in_inches'] }}" name="bmi__at_20_years_old__waistline_in_inches" type="text" class="form-control form-control-sm" placeholder="Answer">
                            <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['bmi__at_20_years_old__waistline_in_inches_unknown'] ? 'checked' : '' }} name="bmi__at_20_years_old__waistline_in_inches_unknown" type="checkbox" class="mr-1">
                                <span>Unknown</span>
                            </label>
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['bmi__at_20_years_old__waistline_in_inches_memo'] }}" name="bmi__at_20_years_old__waistline_in_inches_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                        </div>
                    </div>

                    <div class="my-3 node node-level-4" data-key="bmi__at_20_years_old__height_in_inches">
                        <label>Height in inches?</label>
                        <div class="d-flex align-items-center">
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['bmi__at_20_years_old__height_in_inches'] }}" name="bmi__at_20_years_old__height_in_inches" type="text" class="form-control form-control-sm" placeholder="Answer">
                            <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
                                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['bmi__at_20_years_old__height_in_inches_unknown'] ? 'checked' : '' }} name="bmi__at_20_years_old__height_in_inches_unknown" type="checkbox" class="mr-1">
                                <span>Unknown</span>
                            </label>
                            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['bmi__at_20_years_old__height_in_inches_memo'] }}" name="bmi__at_20_years_old__height_in_inches_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                        </div>
                    </div>

                </div>
            </div>

            <div class="my-3 node node-level-2" data-key="bmi__weight_goal_today">
                <label>Personal weight goal today</label>
                <div class="d-flex align-items-center">
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['bmi__weight_goal_today'] }}" name="bmi__weight_goal_today" type="text" class="form-control form-control-sm" placeholder="Answer">
                    <label class="d-inline-flex align-items-center my-0 ml-3 mr-2">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['bmi__weight_goal_today_unknown'] ? 'checked' : '' }} name="bmi__weight_goal_today_unknown" type="checkbox" class="mr-1">
                        <span>Unknown</span>
                    </label>
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['bmi__weight_goal_today_memo'] }}" name="bmi__weight_goal_today_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                </div>
            </div>

            <div class="my-3 node node-level-2" data-key="bmi__barriers_to_exercise">
                <label>Do you currently have any conditions, such as arthritis or joint pain, that limit your ability to exercise?</label>
                <div class="d-flex align-items-center">
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['bmi__barriers_to_exercise'] }}" name="bmi__barriers_to_exercise" type="text" class="form-control form-control-sm mr-2" placeholder="Answer">
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['bmi__barriers_to_exercise_memo'] }}" name="bmi__barriers_to_exercise_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                </div>
            </div>

        </div>
    </div>

    <div class="my-3 node node-level-0" data-key="current_focus_areas">
        <label>As you know, you get three things with this program: 1) dedicated NP, 2) 24/7 access to the hotline, and 3) self-monitoring kit. What conditions or health goals do you have that you would like to see improve by participating in this program?</label>
        <div class="mt-3">
            <label class="d-flex align-items-center mb-1 mr-2">
                <input onchange="onGemVChange_{{ $formID }}(this)" {{ isset($contentData['current_focus_areas']) && in_array('High Blood Pressure', $contentData['current_focus_areas']) !== FALSE ? 'checked' : '' }} name="current_focus_areas[]" value="High Blood Pressure" type="checkbox" class="mr-1">
                <span>High Blood Pressure</span>
            </label>
            <label class="d-flex align-items-center mb-1 mr-2">
                <input onchange="onGemVChange_{{ $formID }}(this)" {{ isset($contentData['current_focus_areas']) && in_array('Heart Disease', $contentData['current_focus_areas']) !== FALSE ? 'checked' : '' }} name="current_focus_areas[]" value="Heart Disease" type="checkbox" class="mr-1">
                <span>Heart Disease</span>
            </label>
            <label class="d-flex align-items-center mb-1 mr-2">
                <input onchange="onGemVChange_{{ $formID }}(this)" {{ isset($contentData['current_focus_areas']) && in_array('Diabetes', $contentData['current_focus_areas']) !== FALSE ? 'checked' : '' }} name="current_focus_areas[]" value="Diabetes" type="checkbox" class="mr-1">
                <span>Diabetes</span>
            </label>
            <label class="d-flex align-items-center mb-1 mr-2">
                <input onchange="onGemVChange_{{ $formID }}(this)" {{ isset($contentData['current_focus_areas']) && in_array('Chronic Lung Disease or COPD', $contentData['current_focus_areas']) !== FALSE ? 'checked' : '' }} name="current_focus_areas[]" value="Chronic Lung Disease or COPD" type="checkbox" class="mr-1">
                <span>Chronic Lung Disease or COPD</span>
            </label>
            <label class="d-flex align-items-center mb-1 mr-2">
                <input onchange="onGemVChange_{{ $formID }}(this)" {{ isset($contentData['current_focus_areas']) && in_array('High Cholesterol', $contentData['current_focus_areas']) !== FALSE ? 'checked' : '' }} name="current_focus_areas[]" value="High Cholesterol" type="checkbox" class="mr-1">
                <span>High Cholesterol</span>
            </label>
            <label class="d-flex align-items-center mb-1 mr-2">
                <input onchange="onGemVChange_{{ $formID }}(this)" {{ isset($contentData['current_focus_areas']) && in_array('Heart Failure', $contentData['current_focus_areas']) !== FALSE ? 'checked' : '' }} name="current_focus_areas[]" value="Heart Failure" type="checkbox" class="mr-1">
                <span>Heart Failure</span>
            </label>
            <label class="d-flex align-items-center mb-1 mr-2">
                <input onchange="onGemVChange_{{ $formID }}(this)" {{ isset($contentData['current_focus_areas']) && in_array('Atherosclerotic Disease (\'Clogged Artery\')', $contentData['current_focus_areas']) !== FALSE ? 'checked' : '' }} name="current_focus_areas[]" value="Atherosclerotic Disease ('Clogged Artery')" type="checkbox" class="mr-1">
                <span>Atherosclerotic Disease ('Clogged Artery')</span>
            </label>
            <label class="d-flex align-items-center mb-1 mr-2">
                <input onchange="onGemVChange_{{ $formID }}(this)" {{ isset($contentData['current_focus_areas']) && in_array('Cancer', $contentData['current_focus_areas']) !== FALSE ? 'checked' : '' }} name="current_focus_areas[]" value="Cancer" type="checkbox" class="mr-1">
                <span>Cancer</span>
            </label>
            <label class="d-flex align-items-center mb-1 mr-2">
                <input onchange="onGemVChange_{{ $formID }}(this)" {{ isset($contentData['current_focus_areas']) && in_array('Stroke', $contentData['current_focus_areas']) !== FALSE ? 'checked' : '' }} name="current_focus_areas[]" value="Stroke" type="checkbox" class="mr-1">
                <span>Stroke</span>
            </label>
            <label class="d-flex align-items-center mb-1 mr-2">
                <input onchange="onGemVChange_{{ $formID }}(this)" {{ isset($contentData['current_focus_areas']) && in_array('Alzheimer\'s', $contentData['current_focus_areas']) !== FALSE ? 'checked' : '' }} name="current_focus_areas[]" value="Alzheimer's" type="checkbox" class="mr-1">
                <span>Alzheimer's</span>
            </label>
            <label class="d-flex align-items-center mb-1 mr-2">
                <input onchange="onGemVChange_{{ $formID }}(this)" {{ isset($contentData['current_focus_areas']) && in_array('Diabetes', $contentData['current_focus_areas']) !== FALSE ? 'checked' : '' }} name="current_focus_areas[]" value="Diabetes" type="checkbox" class="mr-1">
                <span>Diabetes</span>
            </label>
            <label class="d-flex align-items-center mb-1 mr-2">
                <input onchange="onGemVChange_{{ $formID }}(this)" {{ isset($contentData['current_focus_areas']) && in_array('Kidney Disease', $contentData['current_focus_areas']) !== FALSE ? 'checked' : '' }} name="current_focus_areas[]" value="Kidney Disease" type="checkbox" class="mr-1">
                <span>Kidney Disease</span>
            </label>
            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['current_focus_areas_other'] }}" name="current_focus_areas_other" type="text" class="form-control form-control-sm my-3" placeholder="Other">
        </div>
    </div>

    <div class="my-3 node node-level-0" data-key="consent">
        <label>Consent:</label>
        <div class="subs pl-4">
            <div class="my-3 node node-level-2" data-key="consent__to_be_treated_and_use_equipment_as_directed">
                <label>Do you agree to be treated for the above <span field="current_focus_areas"></span> by our board-certified nurse practitioners using self-monitoring equipment as directed for safety purposes - and do you understand that improper use of the equipment may cause false readings and possible harm?</label>
                <div class="d-flex align-items-center">
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['consent__to_be_treated_and_use_equipment_as_directed'] === 'ACCEPT' ? 'checked' : '' }} name="consent__to_be_treated_and_use_equipment_as_directed" type="radio" value="ACCEPT" class="mr-1">
                        <span>Accept</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['consent__to_be_treated_and_use_equipment_as_directed'] === 'REJECT' ? 'checked' : '' }} name="consent__to_be_treated_and_use_equipment_as_directed" type="radio" value="REJECT" class="mr-1">
                        <span>Reject</span>
                    </label>
                </div>
            </div>

            <div class="my-3 node node-level-2" data-key="consent__np_to_do_consult">
                <label>I have to transfer this call over to the on call NP, who will conduct an initial consultation and sign the equipment order.</label>
                <div class="d-flex align-items-center">
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['consent__np_to_do_consult'] === 'ACCEPT' ? 'checked' : '' }} name="consent__np_to_do_consult" type="radio" value="ACCEPT" class="mr-1">
                        <span>Accept</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['consent__np_to_do_consult'] === 'REJECT' ? 'checked' : '' }} name="consent__np_to_do_consult" type="radio" value="REJECT" class="mr-1">
                        <span>Reject</span>
                    </label>
                </div>
            </div>

            <div class="my-3 node node-level-2" data-key="consent__np_will_be_poc">
                <label>She'll be your dedicated point of contact here.</label>
                <div class="d-flex align-items-center">
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['consent__np_will_be_poc'] === 'ACCEPT' ? 'checked' : '' }} name="consent__np_will_be_poc" type="radio" value="ACCEPT" class="mr-1">
                        <span>Accept</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['consent__np_will_be_poc'] === 'REJECT' ? 'checked' : '' }} name="consent__np_will_be_poc" type="radio" value="REJECT" class="mr-1">
                        <span>Reject</span>
                    </label>
                </div>
            </div>

            <div class="my-3 node node-level-2" data-key="consent__confirm_ox_follow_up">
                <label>As we discussed earlier, once you receive the oxygen meter, your dedicated NP will follow up again in a few days, it can be simply over the phone or video call if needed, to get a baseline resting and active oxygen reading. Number to call: <span field="blood_ox__o2_and_activity__baseline_o2_assessment__best_number_to_call"></span>, Time to call: <span field="blood_ox__o2_and_activity__baseline_o2_assessment__best_time_to_call"></span>.</label>
                <div class="d-flex align-items-center">
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['consent__confirm_ox_follow_up'] === 'ACCEPT' ? 'checked' : '' }} name="consent__confirm_ox_follow_up" type="radio" value="ACCEPT" class="mr-1">
                        <span>Accept</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['consent__confirm_ox_follow_up'] === 'REJECT' ? 'checked' : '' }} name="consent__confirm_ox_follow_up" type="radio" value="REJECT" class="mr-1">
                        <span>Reject</span>
                    </label>
                </div>
            </div>

            <div class="my-3 node node-level-2" data-key="consent__monthly_follow_up">
                <label>After you are set up, your dedicated NP is required to call you monthly to make sure that you are okay and that the equipment is working properly.</label>
                <div class="d-flex align-items-center">
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['consent__monthly_follow_up'] === 'ACCEPT' ? 'checked' : '' }} name="consent__monthly_follow_up" type="radio" value="ACCEPT" class="mr-1">
                        <span>Accept</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['consent__monthly_follow_up'] === 'REJECT' ? 'checked' : '' }} name="consent__monthly_follow_up" type="radio" value="REJECT" class="mr-1">
                        <span>Reject</span>
                    </label>
                </div>
            </div>

            <div class="my-3 node node-level-2" data-key="consent__package">
                <label>The equipment will come in two packages. First the temperature gun and oxygen meter. Then when we have confirmation that you successfully received the first package and got your baseline oxygen measurement, we will send out the second package which contains the BP cuff and weight scale.</label>
                <div class="d-flex align-items-center">
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['consent__package'] === 'ACCEPT' ? 'checked' : '' }} name="consent__package" type="radio" value="ACCEPT" class="mr-1">
                        <span>Accept</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['consent__package'] === 'REJECT' ? 'checked' : '' }} name="consent__package" type="radio" value="REJECT" class="mr-1">
                        <span>Reject</span>
                    </label>
                </div>
            </div>

            <div class="my-3 node node-level-2" data-key="consent__video_call">
                <label>This first call with the NP, to sign the order, has to be a video call.</label>
                <div class="d-flex align-items-center">
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['consent__video_call'] === 'ACCEPT' ? 'checked' : '' }} name="consent__video_call" type="radio" value="ACCEPT" class="mr-1">
                        <span>Accept</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['consent__video_call'] === 'REJECT' ? 'checked' : '' }} name="consent__video_call" type="radio" value="REJECT" class="mr-1">
                        <span>Reject</span>
                    </label>
                </div>
            </div>

            <div class="my-3 node node-level-2" data-key="consent__later_phone_call">
                <label>This is the only time a video call is required - if you need anything in the future it can be over a normal phone call.</label>
                <div class="d-flex align-items-center">
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['consent__later_phone_call'] === 'ACCEPT' ? 'checked' : '' }} name="consent__later_phone_call" type="radio" value="ACCEPT" class="mr-1">
                        <span>Accept</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['consent__later_phone_call'] === 'REJECT' ? 'checked' : '' }} name="consent__later_phone_call" type="radio" value="REJECT" class="mr-1">
                        <span>Reject</span>
                    </label>
                </div>
            </div>

        </div>
    </div>

    <div class="my-3 node node-level-0" data-key="ever_had_a_video_call_with_hcp">
        <label>Have you ever had a video call with one of your other doctors before?</label>
        <div class="d-flex align-items-center">
            <label class="d-inline-flex align-items-center my-0 mr-3">
                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['ever_had_a_video_call_with_hcp'] === 'YES' ? 'checked' : '' }} name="ever_had_a_video_call_with_hcp" type="radio" value="YES" class="mr-1">
                <span>Yes</span>
            </label>
            <label class="d-inline-flex align-items-center my-0 mr-3">
                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['ever_had_a_video_call_with_hcp'] === 'NO' ? 'checked' : '' }} name="ever_had_a_video_call_with_hcp" type="radio" value="NO" class="mr-1">
                <span>No</span>
            </label>
            <label class="d-inline-flex align-items-center my-0 mr-3">
                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['ever_had_a_video_call_with_hcp'] === 'UNKNOWN' ? 'checked' : '' }} name="ever_had_a_video_call_with_hcp" type="radio" value="UNKNOWN" class="mr-1">
                <span>Unknown</span>
            </label>
            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['ever_had_a_video_call_with_hcp_memo'] }}" name="ever_had_a_video_call_with_hcp_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
        </div>
        <div class="subs pl-4">
            <div class="my-3 node node-level-2" data-key="ever_had_a_video_call_with_hcp__how_did_you_do_it">
                <label>How did you do it?</label>
                <div class="d-flex align-items-center">
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['ever_had_a_video_call_with_hcp__how_did_you_do_it'] }}" name="ever_had_a_video_call_with_hcp__how_did_you_do_it" type="text" class="form-control form-control-sm mr-2" placeholder="Answer">
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['ever_had_a_video_call_with_hcp__how_did_you_do_it_memo'] }}" name="ever_had_a_video_call_with_hcp__how_did_you_do_it_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                </div>
            </div>

            <div class="my-3 node node-level-2" data-key="ever_had_a_video_call_with_hcp__how_did_you_like_it">
                <label>How did you like it?</label>
                <div class="d-flex align-items-center">
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['ever_had_a_video_call_with_hcp__how_did_you_like_it'] }}" name="ever_had_a_video_call_with_hcp__how_did_you_like_it" type="text" class="form-control form-control-sm mr-2" placeholder="Answer">
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['ever_had_a_video_call_with_hcp__how_did_you_like_it_memo'] }}" name="ever_had_a_video_call_with_hcp__how_did_you_like_it_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                </div>
            </div>

        </div>
    </div>

    <div class="my-3 node node-level-0" data-key="mobile_phone">
        <label>What kind of cell phone do you have?</label>
        <div class="d-flex align-items-center">
            <label class="d-inline-flex align-items-center my-0 mr-3">
                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['mobile_phone'] === 'YES' ? 'checked' : '' }} name="mobile_phone" type="radio" value="YES" class="mr-1">
                <span>Yes</span>
            </label>
            <label class="d-inline-flex align-items-center my-0 mr-3">
                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['mobile_phone'] === 'NO' ? 'checked' : '' }} name="mobile_phone" type="radio" value="NO" class="mr-1">
                <span>No</span>
            </label>
            <label class="d-inline-flex align-items-center my-0 mr-3">
                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['mobile_phone'] === 'UNKNOWN' ? 'checked' : '' }} name="mobile_phone" type="radio" value="UNKNOWN" class="mr-1">
                <span>Unknown</span>
            </label>
            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['mobile_phone_memo'] }}" name="mobile_phone_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
        </div>
        <div class="subs pl-4">
            <div class="my-3 node node-level-2" data-key="mobile_phone__type">
                <label>Type of phone:</label>
                <div class="d-flex align-items-center">
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['mobile_phone__type'] }}" name="mobile_phone__type" type="text" class="form-control form-control-sm mr-2" placeholder="Answer">
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['mobile_phone__type_memo'] }}" name="mobile_phone__type_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                </div>
            </div>

            <div class="my-3 node node-level-2" data-key="mobile_phone__ever_done_video_call_with_phone">
                <label>Have you ever done a video call with your phone before?</label>
                <div class="d-flex align-items-center">
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['mobile_phone__ever_done_video_call_with_phone'] === 'YES' ? 'checked' : '' }} name="mobile_phone__ever_done_video_call_with_phone" type="radio" value="YES" class="mr-1">
                        <span>Yes</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['mobile_phone__ever_done_video_call_with_phone'] === 'NO' ? 'checked' : '' }} name="mobile_phone__ever_done_video_call_with_phone" type="radio" value="NO" class="mr-1">
                        <span>No</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['mobile_phone__ever_done_video_call_with_phone'] === 'UNKNOWN' ? 'checked' : '' }} name="mobile_phone__ever_done_video_call_with_phone" type="radio" value="UNKNOWN" class="mr-1">
                        <span>Unknown</span>
                    </label>
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['mobile_phone__ever_done_video_call_with_phone_memo'] }}" name="mobile_phone__ever_done_video_call_with_phone_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                </div>
            </div>

        </div>
    </div>

    <div class="my-3 node node-level-0" data-key="video_call_now">
        <label>Can we do the video call now?</label>
        <div class="d-flex align-items-center">
            <label class="d-inline-flex align-items-center my-0 mr-3">
                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['video_call_now'] === 'YES' ? 'checked' : '' }} name="video_call_now" type="radio" value="YES" class="mr-1">
                <span>Yes</span>
            </label>
            <label class="d-inline-flex align-items-center my-0 mr-3">
                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['video_call_now'] === 'NO' ? 'checked' : '' }} name="video_call_now" type="radio" value="NO" class="mr-1">
                <span>No</span>
            </label>
            <label class="d-inline-flex align-items-center my-0 mr-3">
                <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['video_call_now'] === 'UNKNOWN' ? 'checked' : '' }} name="video_call_now" type="radio" value="UNKNOWN" class="mr-1">
                <span>Unknown</span>
            </label>
            <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['video_call_now_memo'] }}" name="video_call_now_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
        </div>
        <div class="subs pl-4">
            <div class="my-3 node node-level-2" data-key="video_call_now__get_on_call_np">
                <label>If yes, I can bring the on-call NP on the line and they'll get you all set up. OK?</label>
                <div class="d-flex align-items-center">
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['video_call_now__get_on_call_np'] === 'ACCEPT' ? 'checked' : '' }} name="video_call_now__get_on_call_np" type="radio" value="ACCEPT" class="mr-1">
                        <span>Accept</span>
                    </label>
                    <label class="d-inline-flex align-items-center my-0 mr-3">
                        <input onchange="onGemVChange_{{ $formID }}(this)" {{ @$contentData['video_call_now__get_on_call_np'] === 'REJECT' ? 'checked' : '' }} name="video_call_now__get_on_call_np" type="radio" value="REJECT" class="mr-1">
                        <span>Reject</span>
                    </label>
                </div>
            </div>

            <div class="my-3 node node-level-2" data-key="video_call_now__when">
                <label>If not, when is a good time?</label>
                <div class="d-flex align-items-center">
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['video_call_now__when'] }}" name="video_call_now__when" type="text" class="form-control form-control-sm mr-2" placeholder="Answer">
                    <input onchange="onGemVChange_{{ $formID }}(this)" value="{{ @$contentData['video_call_now__when_memo'] }}" name="video_call_now__when_memo" type="text" class="form-control form-control-sm" placeholder="Memo">
                </div>
            </div>

        </div>
    </div>

    </div>


    <div class="form-group m-0 d-flex">
        <button class="btn btn-sm btn-primary mr-2">Done</button>
        {{--<button class="btn btn-sm btn-default border" onclick="return cancelForm_NoteSection_{{ $formID }}(this)">Cancel</button>--}}
    </div>
</form>
<script>
    function submitForm_NoteSection_{{ $formID }}(_form) {
        showMask();
        $.post(_form.action, $(_form).serialize(), function(_data) {
            fastReload();
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    function cancelForm_NoteSection_{{ $formID }}(_trigger) {
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        return false;
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    function onGemVChange_{{ $formID }}(_field) {
        let name = _field.name, span = $('span[field="' + _field.name + '"]');
        if(span.length) {
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        else {
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            span = $('span[field="' + name + '"]');
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                    if(this.checked) value.push(this.value);
                });
                span.text(value.join(', '));
            }
        }

        // submit here
        let form = $(_field).closest('form');
        $.post(form[0].action, form.serialize(), function(_data) {
            console.log('Submitted!');
        });
    }
</script>
