{"id":5322,"date":"2026-05-04T15:55:31","date_gmt":"2026-05-04T10:25:31","guid":{"rendered":"https:\/\/theathreya.com\/?page_id=5322"},"modified":"2026-10-28T13:18:37","modified_gmt":"2026-10-28T07:48:37","slug":"medical-questionnaire","status":"publish","type":"page","link":"https:\/\/theathreya.com\/medical-questionnaire\/","title":{"rendered":"Medical Questionnaire"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"5322\" class=\"elementor elementor-5322\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-f349594 e-con-full e-flex e-con e-parent\" data-id=\"f349594\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t<div class=\"elementor-element elementor-element-c8bc29d e-flex e-con-boxed e-con e-child\" data-id=\"c8bc29d\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-9c51ccf ath-bl-bc elementor-widget elementor-widget-breadcrumbs\" data-id=\"9c51ccf\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"breadcrumbs.default\">\n\t\t\t\t\t<p id=\"breadcrumbs\"><span><span><a href=\"https:\/\/theathreya.com\/\">Home<\/a><\/span><\/span><\/p>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-eb429a5 ath-bl-eyebrow elementor-widget elementor-widget-text-editor\" data-id=\"eb429a5\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>Contact Us \u00b7 Medical Questionnaire<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-cc23dec elementor-widget__width-initial elementor-widget elementor-widget-heading\" data-id=\"cc23dec\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Athreya Medical Questionnaire:<br><span style=\"color:#EEEE22\">Tell Us About Your Health<\/span><\/h1>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-b98a714 elementor-widget__width-initial elementor-widget-mobile__width-initial elementor-widget elementor-widget-text-editor\" data-id=\"b98a714\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>Welcome to Athreya Ayurvedic Centre, Kottayam, Kerala. Share your health history so our doctors can review your case. There is no cost and no obligation.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-0e216ac elementor-align-center ath-bl-btn elementor-widget elementor-widget-button\" data-id=\"0e216ac\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t\t\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"\/online-consultation\/\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">See Consultation Options<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-f63eecf e-con-full ath-d-bodysec e-flex e-con e-parent\" data-id=\"f63eecf\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t<div 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.dp-day.ideal::after{content:\"\";position:absolute;left:50%;bottom:4px;width:5px;height:5px;margin-left:-2.5px;border-radius:50%;background:var(--turmeric,#C99A2E)}\n.ath-mq .dp-day.ideal:not(.e):not(.s){box-shadow:inset 0 0 0 1.5px var(--turmeric,#C99A2E)}\n.ath-mq .dp-day.ideal.e::after{background:#fff}\n.ath-mq .dp-key{display:inline-block;width:14px;height:14px;border-radius:50%;box-shadow:inset 0 0 0 1.5px var(--turmeric,#C99A2E);vertical-align:-2px}\n.ath-mq .dp-tag{display:inline-block;margin-left:6px;padding:2px 8px;border-radius:999px;background:#fbf1dc;color:#8a6414;font:600 .7rem var(--f-body);letter-spacing:.06em;text-transform:uppercase}\n.ath-mq .dp-act{margin-left:auto;display:flex;gap:8px}\n.ath-mq .dp-clear,.ath-mq .dp-done{border-radius:999px;padding:9px 18px;font:600 .75rem var(--f-body);letter-spacing:.08em;text-transform:uppercase;cursor:pointer}\n.ath-mq .dp-clear{border:1px solid var(--line);background:#fff;color:var(--forest)}\n.ath-mq .dp-done{border:0;background:var(--forest);color:#fff}\n.ath-mq .dp-done:disabled{opacity:.4;cursor:default}\n@media (max-width:699px){.ath-mq .dp-month{width:100%}.ath-mq .dp-grid{grid-template-columns:repeat(7,1fr)}.ath-mq .dp-pop{position:fixed;z-index:200;left:12px!important;right:12px;top:auto;bottom:12px;width:auto;max-width:none;padding:14px 12px;max-height:calc(100vh - 24px);overflow:auto;box-shadow:0 -10px 40px rgba(0,0,0,.25)}.ath-mq .dp-act{margin-left:0;width:100%}.ath-mq .dp-act button{flex:1}}\n.ath-mq .btn--gold{background:linear-gradient(90deg,#FCF8C6 0%,#F5C250 70%)!important;color:#043615!important;border:0!important;border-radius:500px!important;padding:19px 33px 19px 32px!important;font:600 16px\/1 \"Bricolage Grotesque\",sans-serif!important}\n.ath-mq .btn--line{background:linear-gradient(90deg,#FFFFFF 0%,#CECECE 70%)!important;color:#043615!important;border:0!important;border-radius:500px!important;padding:19px 33px 19px 32px!important;font:600 16px\/1 \"Bricolage Grotesque\",sans-serif!important}\n.ath-mq .mq-steps li[aria-current]{background:#011F0C!important;color:#B2D670!important}\n.ath-mq .mq-bar i{background:#B2D670!important}\n.ath-mq input,.ath-mq select,.ath-mq textarea{font-family:\"Bricolage Grotesque\",sans-serif}\n.ath-mq [hidden]{display:none!important}\n.ath-mq .btn{text-transform:none!important;letter-spacing:normal!important}\n<\/style>\n<div class=\"ath-mq\"><div class=\"mq\"><div class=\"hipaa\" role=\"note\"><div><b>Your health information is protected<\/b><span>Answers are encrypted and handled under HIPAA-aligned privacy safeguards \u00b7 Secured by JotForm<\/span><\/div><\/div><ol tabindex=\"0\" class=\"mq-steps\"><li aria-current=\"step\">1. About you<\/li><li>2. Your stay<\/li><li>3. Symptoms<\/li><li>4. Covid-19<\/li><li>5. Medical history<\/li><li>6. Daily life<\/li><li>7. Sleep &amp; mind<\/li><li>8. Body check &amp; submit<\/li><\/ol><div class=\"mq-bar\"><i><\/i><\/div><iframe hidden=\"\" name=\"jf-sink\" title=\"JotForm submission\"><\/iframe><form accept-charset=\"utf-8\" action=\"https:\/\/submit.jotform.com\/submit\/220721743746456\" enctype=\"multipart\/form-data\" id=\"mq\" method=\"post\" novalidate=\"\" target=\"jf-sink\"><input name=\"formID\" type=\"hidden\" value=\"220721743746456\"\/><input id=\"simple_spc\" name=\"simple_spc\" type=\"hidden\" value=\"220721743746456\"\/><div aria-hidden=\"true\" style=\"position:absolute;left:-9999px\"><input autocomplete=\"off\" name=\"website\" tabindex=\"-1\" type=\"text\" value=\"\"\/><\/div><fieldset data-step=\"0\"><legend>About you<\/legend><p class=\"sub\">Basic details so our team can reach you.<\/p><div class=\"card\"><div class=\"q\"><span class=\"ql\">Please enter your Full name. <span aria-hidden=\"true\" style=\"color:var(--green)\">*<\/span><\/span><div class=\"two\"><input aria-label=\"First Name\" autocomplete=\"given-name\" id=\"q1a\" name=\"q3_pleaseEnter[first]\" placeholder=\"First Name\" required=\"\" type=\"text\"\/><input aria-label=\"Last Name\" autocomplete=\"family-name\" id=\"q1b\" name=\"q3_pleaseEnter[last]\" placeholder=\"Last Name\" required=\"\" type=\"text\"\/><\/div><\/div><div class=\"q\"><label for=\"q2\">Age<\/label><input id=\"q2\" max=\"300\" min=\"0\" name=\"q40_age\" type=\"number\"\/><\/div><div class=\"q\"><span class=\"ql\">Gender<\/span><div class=\"seg\" role=\"radiogroup\"><label><input id=\"q3-0\" name=\"q41_name41[]\" type=\"radio\" value=\"Male\"\/> Male<\/label><label><input id=\"q3-1\" name=\"q41_name41[]\" type=\"radio\" value=\"Female\"\/> Female<\/label><label><input id=\"q3-2\" name=\"q41_name41[]\" type=\"radio\" value=\"Other\"\/> Other<\/label><label><input id=\"q3-3\" name=\"q41_name41[]\" type=\"radio\" value=\"N\/A\"\/> N\/A<\/label><\/div><\/div><div class=\"q\"><label for=\"q4\">What is your email address can we reach you? <span aria-hidden=\"true\" style=\"color:var(--green)\">*<\/span><\/label><small>This is only to get in touch, not to send spam.<\/small><input autocomplete=\"email\" id=\"q4\" name=\"q6_whatIs\" required=\"\" type=\"email\"\/><\/div><div class=\"q\"><label for=\"q5\">Please provide your phone number. <span aria-hidden=\"true\" style=\"color:var(--green)\">*<\/span><\/label><small>Preferable the one with the active Whatsapp, for better communication. Choose your country code, then type your number.<\/small><input autocomplete=\"tel\" id=\"q5\" name=\"q5_pleaseProvide[full]\" placeholder=\"+00 0000000000\" required=\"\" type=\"tel\"\/><\/div><div class=\"q\"><label for=\"q6\">Emergency Contact <span aria-hidden=\"true\" style=\"color:var(--green)\">*<\/span><\/label><small>Preferable the one with the active Whatsapp, for better communication. Choose your country code, then type your number.<\/small><input autocomplete=\"tel\" id=\"q6\" name=\"q42_emergencyContact[full]\" placeholder=\"+00 0000000000\" required=\"\" type=\"tel\"\/><\/div><div class=\"q\"><label for=\"q7\">Job<\/label><input id=\"q7\" name=\"q43_job\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q8\">How does job effect your health and mind wise?<\/label><textarea id=\"q8\" name=\"q44_howDoes\"><\/textarea><\/div><div class=\"q\"><span class=\"ql\">Are you interested in medical astrology aspects?<\/span><div class=\"seg\" role=\"radiogroup\"><label><input id=\"q9-0\" name=\"q46_areYou\" type=\"radio\" value=\"Yes\"\/> Yes<\/label><label><input id=\"q9-1\" name=\"q46_areYou\" type=\"radio\" value=\"No\"\/> No<\/label><\/div><\/div><div class=\"q\"><label for=\"q10\">Country<\/label><input id=\"q10\" name=\"q47_country\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q11\">City\/Town\/Village<\/label><input id=\"q11\" name=\"q48_citytownvillage\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q12\">Date of Birth <span aria-hidden=\"true\" style=\"color:var(--green)\">*<\/span><\/label><input data-jot=\"q38_dateOf38\" data-kind=\"date\" id=\"q12\" required=\"\" type=\"date\"\/><\/div><div class=\"q\"><label for=\"q13\">Time of Birth<\/label><input data-jot=\"q49_timeOf\" data-kind=\"time\" id=\"q13\" type=\"time\"\/><\/div><\/div><\/fieldset><fieldset data-step=\"1\" hidden=\"\"><legend>Your stay<\/legend><p class=\"sub\">Probable Duration of stay at Athreya<\/p><div class=\"card\"><div class=\"q\"><label for=\"q14\">Start Date<\/label><input data-jot=\"q53_startDate\" data-kind=\"date\" id=\"q14\" type=\"date\"\/><\/div><div class=\"q\"><label for=\"q15\">End Date<\/label><input data-jot=\"q54_endDate\" data-kind=\"date\" id=\"q15\" type=\"date\"\/><\/div><div class=\"q\"><label for=\"q16\">What are your medical social expectations from a trip to Athreya?<\/label><textarea id=\"q16\" name=\"q58_whatAre\"><\/textarea><\/div><\/div><\/fieldset><fieldset data-step=\"2\" hidden=\"\"><legend>Symptoms<\/legend><p class=\"sub\">Tell us what brings you to Athreya.<\/p><div class=\"card\"><div class=\"q\"><label for=\"q17\">Specific list of symptoms bothering you the most<\/label><textarea id=\"q17\" name=\"q55_specificList\"><\/textarea><\/div><div class=\"q\"><label for=\"q18\">Which factors aggravate your symptoms?<\/label><textarea id=\"q18\" name=\"q56_whichFactors\"><\/textarea><\/div><div class=\"q\"><label for=\"q19\">Which factors relieve your symptoms?<\/label><textarea id=\"q19\" name=\"q57_whichFactors57\"><\/textarea><\/div><div class=\"q\"><label for=\"q20\">History of current complaints\/symptoms, their sequence of chronology and their duration:<\/label><textarea id=\"q20\" name=\"q59_historyOf\"><\/textarea><\/div><div class=\"q\"><label for=\"q21\">History of previous aliments that bothered you in chronology<\/label><textarea id=\"q21\" name=\"q60_historyOf60\"><\/textarea><\/div><div class=\"q\"><label for=\"q22\">History of any Ayurvedic therapies &amp; or any form of energy healing therapies and the duration of its effect lasting in body<\/label><textarea id=\"q22\" name=\"q61_historyOf61\"><\/textarea><\/div><div class=\"q\"><label for=\"q23\">Current medication that you are utilizing<\/label><textarea id=\"q23\" name=\"q62_currentMedication\"><\/textarea><\/div><\/div><\/fieldset><fieldset data-step=\"3\" hidden=\"\"><legend>Covid-19<\/legend><p class=\"sub\">Infection and vaccination history.<\/p><div class=\"card\"><div class=\"q\"><span class=\"ql\">Did you ever get Covid-19 positive?<\/span><div class=\"seg\" role=\"radiogroup\"><label><input id=\"q24-0\" name=\"q181_didYou\" type=\"radio\" value=\"YES\"\/> YES<\/label><label><input id=\"q24-1\" name=\"q181_didYou\" type=\"radio\" value=\"NO\"\/> NO<\/label><\/div><\/div><div class=\"q\"><span class=\"ql\">Do you suffer from any post Covid-19 Symptoms?<\/span><div class=\"seg\" role=\"radiogroup\"><label><input id=\"q25-0\" name=\"q182_doYou182[]\" type=\"radio\" value=\"YES\"\/> YES<\/label><label><input id=\"q25-1\" name=\"q182_doYou182[]\" type=\"radio\" value=\"NO\"\/> NO<\/label><\/div><\/div><div class=\"q\"><label for=\"q26\">If yes, please elaborate with duration<\/label><textarea id=\"q26\" name=\"q184_ifYes\"><\/textarea><\/div><div class=\"q\"><span class=\"ql\">Did you get vaccinated against Covid-19?<\/span><div class=\"seg\" role=\"radiogroup\"><label><input id=\"q27-0\" name=\"q185_didYou185[]\" type=\"radio\" value=\"YES\"\/> YES<\/label><label><input id=\"q27-1\" name=\"q185_didYou185[]\" type=\"radio\" value=\"NO\"\/> NO<\/label><\/div><\/div><div class=\"q\"><label for=\"q28\">Any positive side effects?<\/label><textarea id=\"q28\" name=\"q186_anyPositive\"><\/textarea><\/div><div class=\"q\"><label for=\"q29\">If yes, please elaborate the symptoms faced with duration<\/label><textarea id=\"q29\" name=\"q187_ifYes187\"><\/textarea><\/div><div class=\"q\"><label for=\"q30\">Any negative side effects<\/label><textarea id=\"q30\" name=\"q188_anyNegative\"><\/textarea><\/div><div class=\"q\"><label for=\"q31\">If yes, please elaborate the symptoms faced with duration<\/label><textarea id=\"q31\" name=\"q189_ifYes189\"><\/textarea><\/div><\/div><\/fieldset><fieldset data-step=\"4\" hidden=\"\"><legend>Medical history<\/legend><p class=\"sub\">For each condition, tell us if you have it and whether it runs in your family.<\/p><div class=\"card\"><div class=\"tbl\" tabindex=\"0\" role=\"region\" aria-label=\"Table\" style=\"background:#fff;padding:4px 12px\"><table class=\"hx\"><thead><tr><th>Condition<\/th><th>You<\/th><th>Family History<\/th><\/tr><\/thead><tbody><tr><td>Diabetes<\/td><td><div class=\"yn\"><label><input name=\"q63_diabetes\" type=\"radio\" value=\"Yes\"\/> Yes<\/label><label><input name=\"q63_diabetes\" type=\"radio\" value=\"No\"\/> No<\/label><\/div><\/td><td><input aria-label=\"Diabetes Family History\" id=\"q32-0-fh\" name=\"q64_diabetesFamily\" placeholder=\"Family history\" type=\"text\"\/><\/td><\/tr><tr><td>Tuberculosis<\/td><td><div class=\"yn\"><label><input name=\"q65_tuberculosis\" type=\"radio\" value=\"Yes\"\/> Yes<\/label><label><input name=\"q65_tuberculosis\" type=\"radio\" value=\"No\"\/> No<\/label><\/div><\/td><td><input aria-label=\"Tuberculosis Family History\" id=\"q32-1-fh\" name=\"q74_tuberculosisFamily\" placeholder=\"Family history\" type=\"text\"\/><\/td><\/tr><tr><td>Bronchitis<\/td><td><div class=\"yn\"><label><input name=\"q75_bronchitis\" type=\"radio\" value=\"Yes\"\/> Yes<\/label><label><input name=\"q75_bronchitis\" type=\"radio\" value=\"No\"\/> No<\/label><\/div><\/td><td><input aria-label=\"Bronchitis Family History\" id=\"q32-2-fh\" name=\"q77_bronchitisFamily\" placeholder=\"Family history\" type=\"text\"\/><\/td><\/tr><tr><td>Asthma<\/td><td><div class=\"yn\"><label><input name=\"q79_asthma\" type=\"radio\" value=\"Yes\"\/> Yes<\/label><label><input name=\"q79_asthma\" type=\"radio\" value=\"No\"\/> No<\/label><\/div><\/td><td><input aria-label=\"Asthma Family History\" id=\"q32-3-fh\" name=\"q78_asthmaFamily\" placeholder=\"Family history\" type=\"text\"\/><\/td><\/tr><tr><td>Heart Disease<\/td><td><div class=\"yn\"><label><input name=\"q80_heartDisease\" type=\"radio\" value=\"Yes\"\/> Yes<\/label><label><input name=\"q80_heartDisease\" type=\"radio\" value=\"No\"\/> No<\/label><\/div><\/td><td><input aria-label=\"Heart Disease Family History\" id=\"q32-4-fh\" name=\"q81_heartDisease81\" placeholder=\"Family history\" type=\"text\"\/><\/td><\/tr><tr><td>Thyroid Disease<\/td><td><div class=\"yn\"><label><input name=\"q88_thyroiddisease\" type=\"radio\" value=\"Yes\"\/> Yes<\/label><label><input name=\"q88_thyroiddisease\" type=\"radio\" value=\"No\"\/> No<\/label><\/div><\/td><td><input aria-label=\"Thyroid Disease Family History\" id=\"q32-5-fh\" name=\"q89_thyroiddiseaseFamily\" placeholder=\"Family history\" type=\"text\"\/><\/td><\/tr><tr><td>Anemia<\/td><td><div class=\"yn\"><label><input name=\"q92_anemia\" type=\"radio\" value=\"Yes\"\/> Yes<\/label><label><input name=\"q92_anemia\" type=\"radio\" value=\"No\"\/> No<\/label><\/div><\/td><td><input aria-label=\"Anemia Family History\" id=\"q32-6-fh\" name=\"q93_anemiafamilyHistory\" placeholder=\"Family history\" type=\"text\"\/><\/td><\/tr><tr><td>Skin Disorders<\/td><td><div class=\"yn\"><label><input name=\"q94_skinDisorders94\" type=\"radio\" value=\"Yes\"\/> Yes<\/label><label><input name=\"q94_skinDisorders94\" type=\"radio\" value=\"No\"\/> No<\/label><\/div><\/td><td><input aria-label=\"Skin Disorders Family History\" id=\"q32-7-fh\" name=\"q95_skinDisorders95\" placeholder=\"Family history\" type=\"text\"\/><\/td><\/tr><tr><td>Jaundice<\/td><td><div class=\"yn\"><label><input name=\"q96_jaundice\" type=\"radio\" value=\"Yes\"\/> Yes<\/label><label><input name=\"q96_jaundice\" type=\"radio\" value=\"No\"\/> No<\/label><\/div><\/td><td><input aria-label=\"Jaundice Family History\" id=\"q32-8-fh\" name=\"q97_jaundicefamilyHistory\" placeholder=\"Family history\" type=\"text\"\/><\/td><\/tr><tr><td>Epilepsy<\/td><td><div class=\"yn\"><label><input name=\"q98_epilepsy\" type=\"radio\" value=\"Yes\"\/> Yes<\/label><label><input name=\"q98_epilepsy\" type=\"radio\" value=\"No\"\/> No<\/label><\/div><\/td><td><input aria-label=\"Epilepsy Family History\" id=\"q32-9-fh\" name=\"q99_epilepsyfamilyHistory\" placeholder=\"Family history\" type=\"text\"\/><\/td><\/tr><tr><td>Urinary Disorder<\/td><td><div class=\"yn\"><label><input name=\"q100_urinaryDisorder\" type=\"radio\" value=\"Yes\"\/> Yes<\/label><label><input name=\"q100_urinaryDisorder\" type=\"radio\" value=\"No\"\/> No<\/label><\/div><\/td><td><input aria-label=\"Urinary Disorder Family History\" id=\"q32-10-fh\" name=\"q101_urinaryDisorder101\" placeholder=\"Family history\" type=\"text\"\/><\/td><\/tr><tr><td>Neurological Disease<\/td><td><div class=\"yn\"><label><input name=\"q102_neurologicalDisease\" type=\"radio\" value=\"Yes\"\/> Yes<\/label><label><input name=\"q102_neurologicalDisease\" type=\"radio\" value=\"No\"\/> No<\/label><\/div><\/td><td><input aria-label=\"Neurological Disease Family History\" id=\"q32-11-fh\" name=\"q103_neurologicalDisease103\" placeholder=\"Family history\" type=\"text\"\/><\/td><\/tr><tr><td>Kidney Disease<\/td><td><div class=\"yn\"><label><input name=\"q104_kidneydisease\" type=\"radio\" value=\"Yes\"\/> Yes<\/label><label><input name=\"q104_kidneydisease\" type=\"radio\" value=\"No\"\/> No<\/label><\/div><\/td><td><input aria-label=\"Kidney Disease Family History\" id=\"q32-12-fh\" name=\"q105_kidneydiseaseFamily\" placeholder=\"Family history\" type=\"text\"\/><\/td><\/tr><tr><td>Blood Disease<\/td><td><div class=\"yn\"><label><input name=\"q106_blooddisease\" type=\"radio\" value=\"Yes\"\/> Yes<\/label><label><input name=\"q106_blooddisease\" type=\"radio\" value=\"No\"\/> No<\/label><\/div><\/td><td><input aria-label=\"Blood Disease Family History\" id=\"q32-13-fh\" name=\"q107_blooddiseaseFamily\" placeholder=\"Family history\" type=\"text\"\/><\/td><\/tr><tr><td>Digestive Disease<\/td><td><div class=\"yn\"><label><input name=\"q108_digestivedisease\" type=\"radio\" value=\"Yes\"\/> Yes<\/label><label><input name=\"q108_digestivedisease\" type=\"radio\" value=\"No\"\/> No<\/label><\/div><\/td><td><input aria-label=\"Digestive Disease Family History\" id=\"q32-14-fh\" name=\"q109_digestivediseaseFamily\" placeholder=\"Family history\" type=\"text\"\/><\/td><\/tr><tr><td>Hyper Acidity<\/td><td><div class=\"yn\"><label><input name=\"q110_hyperAcidity\" type=\"radio\" value=\"Yes\"\/> Yes<\/label><label><input name=\"q110_hyperAcidity\" type=\"radio\" value=\"No\"\/> No<\/label><\/div><\/td><td><input aria-label=\"Hyper Acidity Family History\" id=\"q32-15-fh\" name=\"q111_hyperAcidity111\" placeholder=\"Family history\" type=\"text\"\/><\/td><\/tr><tr><td>Hemorrhoids (piles)<\/td><td><div class=\"yn\"><label><input name=\"q112_hemorrhoidspiles\" type=\"radio\" value=\"Yes\"\/> Yes<\/label><label><input name=\"q112_hemorrhoidspiles\" type=\"radio\" value=\"No\"\/> No<\/label><\/div><\/td><td><input aria-label=\"Hemorrhoids (piles) Family History\" id=\"q32-16-fh\" name=\"q113_hemorrhoidspiles113\" placeholder=\"Family history\" type=\"text\"\/><\/td><\/tr><tr><td>Cancer(s)<\/td><td><div class=\"yn\"><label><input name=\"q114_cancers\" type=\"radio\" value=\"Yes\"\/> Yes<\/label><label><input name=\"q114_cancers\" type=\"radio\" value=\"No\"\/> No<\/label><\/div><\/td><td><input aria-label=\"Cancer(s) Family History\" id=\"q32-17-fh\" name=\"q115_cancersFamily\" placeholder=\"Family history\" type=\"text\"\/><\/td><\/tr><\/tbody><\/table><\/div><div class=\"q\"><label for=\"q33\">Allergies towards, please enumerate:<\/label><textarea id=\"q33\" name=\"q120_allergiesTowards\"><\/textarea><\/div><div class=\"q\"><label for=\"q34\">Injuries<\/label><textarea id=\"q34\" name=\"q121_injuries\"><\/textarea><\/div><div class=\"q\"><label for=\"q35\">Surgeries<\/label><textarea id=\"q35\" name=\"q122_surgeries\"><\/textarea><\/div><\/div><\/fieldset><fieldset data-step=\"5\" hidden=\"\"><legend>Daily life<\/legend><p class=\"sub\">Habits, diet, bowel and bladder.<\/p><div class=\"card\"><div class=\"q\"><label for=\"q36\">Daily habits \u2013 from waking up till sleeping time duration of gadgets usage \u2013 mobile, desktop, pc, etc.<\/label><textarea id=\"q36\" name=\"q123_dailyHabits\"><\/textarea><\/div><div class=\"q\"><label for=\"q37\">Addictions to smoke, liquor, drugs any substances?<\/label><textarea id=\"q37\" name=\"q124_addictionsTo\"><\/textarea><\/div><div class=\"q\"><label for=\"q38\">Appetite do you feel definite, timely hunger?<\/label><input id=\"q38\" name=\"q125_appetiteDo\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q39\">Involved any religious or spiritual practices, yoga, chanting of mantras, prayers, occult practices, exercise patterns<\/label><textarea id=\"q39\" name=\"q126_involvedAny\"><\/textarea><\/div><div class=\"q\"><label for=\"q40\">Time gap between consecutive meal time?<\/label><input id=\"q40\" name=\"q127_timeGap\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q41\">Quantity of water intake?<\/label><input id=\"q41\" name=\"q128_quantityOf\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q42\">Ice cold \/ normal \/ warm water intake?<\/label><input id=\"q42\" name=\"q129_iceCold\" type=\"text\"\/><\/div><h3 style=\"margin:26px 0 12px;color:var(--forest)\">Bowel habit<\/h3><div class=\"q\"><label for=\"q44\">How often in a day or week do you visit toilet?<\/label><input id=\"q44\" name=\"q132_howOften\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q45\">Stools float or sink in water of toilet closet?<\/label><input id=\"q45\" name=\"q133_stoolsFloat\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q46\">It is satisfactory evacuation? Or Incomplete bowel evacuation?<\/label><input id=\"q46\" name=\"q134_itIs\" type=\"text\"\/><\/div><h3 style=\"margin:26px 0 12px;color:var(--forest)\">Bladder habit<\/h3><div class=\"q\"><label for=\"q48\">How many seconds does the standard urination last in one session\/stretch?<\/label><input id=\"q48\" name=\"q137_howMany\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q49\">Incontinence of urine?<\/label><input id=\"q49\" name=\"q138_incontinenceOf\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q50\">Burning sensation urine?<\/label><input id=\"q50\" name=\"q139_burningSensation\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q51\">Non pale or dark color urine through out day?<\/label><input id=\"q51\" name=\"q140_nonPale\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q52\">Sweating easily or with difficult?<\/label><input id=\"q52\" name=\"q142_sweatingEasily\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q53\">Foul smell to clothes by sweat?<\/label><input id=\"q53\" name=\"q143_foulSmell\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q54\">Habit of subjecting body to high heat &amp; severe cold temperature fluctuation in quick succession in short time span?<\/label><textarea id=\"q54\" name=\"q144_habitOf\"><\/textarea><\/div><div class=\"q\"><label for=\"q55\">Any head oil used regularly?<\/label><input id=\"q55\" name=\"q145_anyHead\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q56\">Body shower in hot water?<\/label><input id=\"q56\" name=\"q146_bodyShower\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q57\">Hot water for head wash?<\/label><input id=\"q57\" name=\"q147_hotWater\" type=\"text\"\/><\/div><\/div><\/fieldset><fieldset data-step=\"6\" hidden=\"\"><legend>Sleep &amp; mind<\/legend><p class=\"sub\">How you rest and how you feel.<\/p><div class=\"card\"><div class=\"q\"><label for=\"q58\">Sleep duration (how many hours)<\/label><input id=\"q58\" name=\"q148_sleepDuration\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q59\">Day sleep habits?<\/label><input id=\"q59\" name=\"q149_daySleep\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q60\">Habit of postponing when sleep is demanded by body?<\/label><input id=\"q60\" name=\"q150_habitOf150\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q61\">Feeling tired and drained even after sleeping long hours?<\/label><input id=\"q61\" name=\"q151_feelingTired\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q62\">How many hours of sleep is needed to feel fresh?<\/label><input id=\"q62\" name=\"q152_howMany152\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q63\">Starting trouble in sleep?<\/label><input id=\"q63\" name=\"q153_startingTrouble\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q64\">Breaking, interruption trouble in sleep?<\/label><input id=\"q64\" name=\"q154_breakingInterruption\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q65\">Are you constantly stressed?<\/label><input id=\"q65\" name=\"q155_areYou155\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q66\">Feel emotionally low?<\/label><input id=\"q66\" name=\"q156_feelEmotionally\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q67\">Feel empty\/incomplete?<\/label><input id=\"q67\" name=\"q157_feelEmptyincomplete\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q68\">Personal Family life stress?<\/label><input id=\"q68\" name=\"q158_personalFamily\" type=\"text\"\/><\/div><\/div><\/fieldset><fieldset data-step=\"7\" hidden=\"\"><legend>Body check &amp; submit<\/legend><p class=\"sub\">A few final questions, your documents and the declaration.<\/p><div class=\"card\"><div class=\"q\"><label for=\"q69\">Height<\/label><input id=\"q69\" name=\"q160_height\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q70\">Weight<\/label><input id=\"q70\" name=\"q161_weight\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q71\">Blood pressure high or low?<\/label><input id=\"q71\" name=\"q162_bloodPressure\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q72\">Vision symptoms if any, eye sight decreasing? Duration? Using glasses?<\/label><textarea id=\"q72\" name=\"q163_visionSymptoms\"><\/textarea><\/div><div class=\"q\"><label for=\"q73\">Ear \/ symptoms if any, duration?<\/label><input id=\"q73\" name=\"q164_ear\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q74\">Nose\/symptoms if any, duration?<\/label><input id=\"q74\" name=\"q165_nosesymptomsIf\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q75\">Through nose can you make 10 seconds deep breathing in and breath out?<\/label><input id=\"q75\" name=\"q166_throughNose\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q76\">Throat symptoms if any, duration?<\/label><input id=\"q76\" name=\"q167_throatSymptoms\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q77\">Dental symptoms or dental work history<\/label><textarea id=\"q77\" name=\"q168_dentalSymptoms\"><\/textarea><\/div><div class=\"q\"><label for=\"q78\">Mouth symptoms if any, duration?<\/label><input id=\"q78\" name=\"q169_mouthSymptoms\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q79\">Do you feel bitter \/ sour \/ salty \/ sweet taste feeling in mouth without using any such food materials?<\/label><input id=\"q79\" name=\"q170_doYou\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q80\">Do you make daily tongue cleaning?<\/label><input id=\"q80\" name=\"q171_doYou171\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q81\">Is the tongue with coating? Can you look in mirror?<\/label><input id=\"q81\" name=\"q172_isThe\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q82\">Any cardiac history? Do you feel very breathless on climbing stairs or walking uphill?<\/label><textarea id=\"q82\" name=\"q173_anyCardiac\"><\/textarea><\/div><div class=\"q\"><label for=\"q83\">Do you have any major scars on the body from any accident and \/ or surgeries?<\/label><textarea id=\"q83\" name=\"q174_doYou174\"><\/textarea><\/div><div class=\"q\"><label for=\"q84\">Have you had any broken bones?<\/label><input id=\"q84\" name=\"q175_haveYou\" type=\"text\"\/><\/div><div class=\"q\"><label for=\"q85\">Menstrual history and present pattern, regularity, flow quantity, specific features Obstetrics history if relevant<\/label><textarea id=\"q85\" name=\"q176_menstrualHistory\"><\/textarea><\/div><div class=\"q\"><label for=\"q86\">Any Medical Documents (Optional)<\/label><div class=\"drop\"><input accept=\".pdf,.jpg,.jpeg,.png\" id=\"q86\" multiple=\"\" name=\"q177_anyMedical[]\" type=\"file\"\/><p style=\"margin:8px 0 0\">Browse Files \u00b7 PDF, JPG or PNG<\/p><\/div><\/div><div class=\"q\"><label style=\"display:flex;gap:10px;align-items:flex-start;font-weight:400\"><input id=\"q87\" name=\"q35_iHereby\" required=\"\" style=\"margin-top:4px;accent-color:var(--green)\" type=\"checkbox\" value=\"Yes\"\/> <span>I hereby declare that the information given in this application is true and correct to the best of my knowledge and belief. in case any information given in this application proves to be false or incorrect, I shall be responsible for the consequences. <span aria-hidden=\"true\" style=\"color:var(--green)\">*<\/span><\/span><\/label><\/div><\/div><\/fieldset><p class=\"err\" id=\"mq-err\" role=\"alert\"><\/p><div class=\"mq-nav\"><button class=\"btn btn--line\" hidden=\"\" id=\"mq-prev\" type=\"button\">Back<\/button><span><\/span><button class=\"btn btn--gold\" id=\"mq-next\" type=\"button\">Next<\/button><button class=\"btn btn--gold\" hidden=\"\" id=\"mq-submit\" type=\"submit\">Submit<\/button><\/div><\/form><div class=\"mq-done card\" hidden=\"\" id=\"mq-done\"><p class=\"eyebrow\" style=\"justify-content:center\">Thank you<\/p><h2>Your medical questionnaire has been received<\/h2><p class=\"lead\" style=\"margin:0 auto\"><a class=\"ilink dr-link\" href=\"\/founders\/\">Dr. Jayalakshmi G BAMS, Director<\/a> and our team will review it and reply personally within 24\u201348 hours.<\/p><div class=\"ctas\" style=\"justify-content:center\"><a class=\"btn btn--gold\" href=\"\/\">Back to home<\/a><\/div><\/div><p class=\"small\" style=\"color:var(--muted);font-size:.86rem;margin-top:18px\">Your data is secured and encrypted \u00b7 Never shared with third parties<\/p><\/div><\/div>\n<script>\n\/* Country and phone fields: a searchable country picker with flags, a flag + dialling-code picker on phone boxes,\n   and the visitor's country filled in from their time zone. 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No outside service is called. *\/\n(function(){\nvar D={\"c\":[[\"AF\",\"Afghanistan\",93],[\"AL\",\"Albania\",355],[\"DZ\",\"Algeria\",213],[\"AD\",\"Andorra\",376],[\"AO\",\"Angola\",244],[\"AI\",\"Anguilla\",1],[\"AG\",\"Antigua & Barbuda\",1],[\"AR\",\"Argentina\",54],[\"AM\",\"Armenia\",374],[\"AW\",\"Aruba\",297],[\"AU\",\"Australia\",61],[\"AT\",\"Austria\",43],[\"AZ\",\"Azerbaijan\",994],[\"BS\",\"Bahamas\",1],[\"BH\",\"Bahrain\",973],[\"BD\",\"Bangladesh\",880],[\"BB\",\"Barbados\",1],[\"BY\",\"Belarus\",375],[\"BE\",\"Belgium\",32],[\"BZ\",\"Belize\",501],[\"BJ\",\"Benin\",229],[\"BM\",\"Bermuda\",1],[\"BT\",\"Bhutan\",975],[\"BO\",\"Bolivia\",591],[\"BA\",\"Bosnia & Herzegovina\",387],[\"BW\",\"Botswana\",267],[\"BR\",\"Brazil\",55],[\"IO\",\"British Indian Ocean Territory\",246],[\"VG\",\"British Virgin Islands\",1],[\"BN\",\"Brunei\",673],[\"BG\",\"Bulgaria\",359],[\"BF\",\"Burkina 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C=D.c, byIso={}, ESC={'&':'&amp;','<':'&lt;','>':'&gt;','\"':'&quot;'};\nC.forEach(function(r){byIso[r[0]]=r;});\nfunction esc(s){return String(s).replace(\/[&<>\"]\/g,function(c){return ESC[c];});}\nfunction flag(iso){return String.fromCodePoint.apply(null,iso.split('').map(function(ch){return 0x1F1E6+ch.charCodeAt(0)-65;}));}\nfunction fold(s){return s.normalize('NFD').replace(\/[\u0300-\u036f]\/g,'').toLowerCase();}\nfunction detect(){\n try{var z=Intl.DateTimeFormat().resolvedOptions().timeZone;if(z&&D.tz[z])return D.tz[z];}catch(e){}\n var ls=navigator.languages||[navigator.language||''];\n for(var i=0;i<ls.length;i++){var m=\/[-_]([A-Z]{2})$\/i.exec(ls[i]||'');if(m&&byIso[m[1].toUpperCase()])return m[1].toUpperCase();}\n return '';\n}\nvar HOME=detect(), uid=0;\n\n\/* one picker component: kind 'country' shows names, kind 'code' shows +codes *\/\nfunction Picker(kind,iso,onPick){\n var id='ip'+(++uid),self=this;\n var w=document.createElement('div');w.className='ip ip--'+kind;\n w.innerHTML='<button type=\"button\" class=\"ip-btn\" aria-haspopup=\"listbox\" aria-expanded=\"false\"><\/button>'+\n  '<div class=\"ip-pop\" hidden><input type=\"search\" class=\"ip-q\" placeholder=\"Search country'+(kind==='code'?' or code':'')+'\" aria-label=\"Search countries\" autocomplete=\"off\">'+\n  '<ul class=\"ip-list\" role=\"listbox\" id=\"'+id+'\"><\/ul><\/div>';\n var btn=w.querySelector('.ip-btn'),pop=w.querySelector('.ip-pop'),q=w.querySelector('.ip-q'),ul=w.querySelector('.ip-list'),act=-1,shown=[];\n btn.setAttribute('aria-controls',id);\n function face(){var r=byIso[self.iso];\n  btn.innerHTML=r?'<span class=\"ip-flag\">'+flag(r[0])+'<\/span><span class=\"ip-txt\">'+(kind==='code'?'+'+r[2]:esc(r[1]))+'<\/span>'\n                 :'<span class=\"ip-txt ip-ph\">'+(kind==='code'?'Code':'Select your country')+'<\/span>';}\n function list(){var t=fold(q.value.trim()).replace(\/^\\+\/,'');\n  function rank(r){var n=fold(r[1]);if(!t)return 0;if(n.indexOf(t)===0||r[0].toLowerCase()===t)return 1;if(String(r[2]).indexOf(t)===0)return 2;if((' '+n).indexOf(' '+t)>-1)return 3;if(n.indexOf(t)>-1)return 4;return 9;}\n  shown=C.map(function(r){return [rank(r),r];}).filter(function(x){return x[0]<9;}).sort(function(a,b){return a[0]-b[0];}).map(function(x){return x[1];});\n  if(!t&&HOME&&byIso[HOME])shown=[byIso[HOME]].concat(shown.filter(function(r){return r[0]!==HOME;}));\n  ul.innerHTML=shown.length?shown.map(function(r,i){return '<li role=\"option\" id=\"'+id+'-'+i+'\" data-iso=\"'+r[0]+'\" aria-selected=\"'+(r[0]===self.iso)+'\"'+(r[0]===HOME&&!t&&i===0?' class=\"ip-home\"':'')+'><span class=\"ip-flag\">'+flag(r[0])+'<\/span><span class=\"ip-name\">'+esc(r[1])+'<\/span><span class=\"ip-code\">+'+r[2]+'<\/span><\/li>';}).join('')\n   :'<li class=\"ip-none\">No country found<\/li>';\n  act=Math.max(0,shown.findIndex(function(r){return r[0]===self.iso;}));hl();}\n function hl(){[].forEach.call(ul.children,function(li,i){li.classList.toggle('on',i===act);});var a=ul.children[act];if(a&&a.id){q.setAttribute('aria-activedescendant',a.id);a.scrollIntoView({block:'nearest'});}}\n function open(){if(!pop.hidden)return;document.dispatchEvent(new CustomEvent('ip-close'));pop.hidden=false;btn.setAttribute('aria-expanded','true');q.value='';list();q.focus();}\n function close(back){pop.hidden=true;btn.setAttribute('aria-expanded','false');if(back)btn.focus();}\n function pick(iso){self.set(iso);close(true);if(onPick)onPick(iso);}\n btn.addEventListener('click',function(){pop.hidden?open():close();});\n btn.addEventListener('keydown',function(e){if(e.key==='ArrowDown'||e.key==='ArrowUp'){e.preventDefault();open();}});\n q.addEventListener('input',function(){list();});\n q.addEventListener('keydown',function(e){\n  if(e.key==='ArrowDown'){e.preventDefault();act=Math.min(shown.length-1,act+1);hl();}\n  else if(e.key==='ArrowUp'){e.preventDefault();act=Math.max(0,act-1);hl();}\n  else if(e.key==='Enter'){e.preventDefault();if(shown[act])pick(shown[act][0]);}\n  else if(e.key==='Escape'){e.preventDefault();close(true);}\n  else if(e.key==='Tab'){close();}});\n ul.addEventListener('mousedown',function(e){e.preventDefault();});\n ul.addEventListener('click',function(e){var li=e.target.closest('li[data-iso]');if(li)pick(li.dataset.iso);});\n document.addEventListener('ip-close',function(){if(!pop.hidden)close();});\n document.addEventListener('click',function(e){if(!w.contains(e.target)&&!pop.hidden)close();});\n this.el=w;this.btn=btn;this.iso=iso||'';\n this.set=function(v){self.iso=v||'';face();};\n face();\n}\n\n\/* country boxes *\/\nvar pickers=[];\n[].slice.call(document.querySelectorAll('input[autocomplete=\"country-name\"], input[name*=\"country\" i], input[id$=\"country\" i]')).forEach(function(inp){\n if(inp.type&&inp.type!=='text')return;\n var hid=document.createElement('input');hid.type='hidden';if(inp.name)hid.name=inp.name;if(inp.required)hid.required=true;\n var p=new Picker('country',HOME,function(iso){hid.value=byIso[iso][1];hid.dispatchEvent(new Event('change',{bubbles:true}));\n  [].slice.call((inp.form||document).querySelectorAll('.tel-wrap')).forEach(function(t){if(t._code&&!t._code.touched)t._code.set(iso);});});\n if(inp.id)p.btn.id=inp.id;\n hid.value=HOME&&byIso[HOME]?byIso[HOME][1]:'';\n p.el.appendChild(hid);inp.parentNode.replaceChild(p.el,inp);pickers.push(p);\n});\n\n\/* phone boxes *\/\n[].slice.call(document.querySelectorAll('input[type=\"tel\"]')).forEach(function(inp){\n if(inp.closest('.tel-wrap'))return;\n var w=document.createElement('div');w.className='tel-wrap';\n var p=new Picker('code',HOME,function(){p.touched=true;});\n p.btn.setAttribute('aria-label','Country code');\n inp.parentNode.insertBefore(w,inp);w.appendChild(p.el);w.appendChild(inp);w._code=p;\n if(\/^\\+00|^\\+91 98\/.test(inp.placeholder||''))inp.placeholder='Phone number';\n \/* typing +44\u2026 picks the matching code *\/\n inp.addEventListener('input',function(){var v=inp.value.replace(\/[^\\d+]\/g,'');if(v.charAt(0)!=='+')return;var best=null;\n  C.forEach(function(r){var c='+'+r[2];if(v.indexOf(c)===0&&(!best||c.length>('+'+best[2]).length||(c.length===('+'+best[2]).length&&r[0]===HOME)))best=r;});\n  if(best&&!(byIso[p.iso]&&byIso[p.iso][2]===best[2])){p.set(best[0]);p.touched=true;}});\n});\n\n\/* when a form is sent, the number goes out as \"+code number\" *\/\ndocument.addEventListener('submit',function(e){\n [].slice.call(e.target.querySelectorAll('.tel-wrap')).forEach(function(w){\n  var inp=w.querySelector('input[type=\"tel\"]'),r=w._code&&byIso[w._code.iso],v=inp.value.trim();\n  if(v&&r&&v.charAt(0)!=='+')inp.value='+'+r[2]+' '+v.replace(\/^0+\/,'');\n });\n},true);\n})();\n\n\/* Preferred dates: arrival \u2192 departure calendar (two months on wide screens, one on phones), past days blocked,\n   quick 14 \/ 21 \/ 28-night buttons. A single \"Preferred Dates\" box gets \"12 Nov 2026 to 2 Dec 2026 (20 nights)\";\n   a start\/end pair (Medical Questionnaire) gets both dates in their own boxes (YYYY-MM-DD). *\/\n(function(){\nvar MN=['January','February','March','April','May','June','July','August','September','October','November','December'],MS=MN.map(function(m){return m.slice(0,3);}),WD=['Mo','Tu','We','Th','Fr','Sa','Su'];\nfunction d0(d){return new Date(d.getFullYear(),d.getMonth(),d.getDate());}\nfunction iso(d){return d.getFullYear()+'-'+('0'+(d.getMonth()+1)).slice(-2)+'-'+('0'+d.getDate()).slice(-2);}\nfunction nice(d){return d.getDate()+' '+MS[d.getMonth()]+' '+d.getFullYear();}\nfunction nights(a,b){return Math.round((b-a)\/864e5);}\nfunction parse(v){var m=\/^(\\d{4})-(\\d{2})-(\\d{2})$\/.exec(v||'');return m?new Date(+m[1],m[2]-1,+m[3]):null;}\nvar TODAY=d0(new Date()),IDEAL=21;\n\nfunction Range(fields,mode){ \/* fields: [single] or [start,end] *\/\n var st={a:null,b:null,hover:null,view:new Date(TODAY.getFullYear(),TODAY.getMonth(),1)},self=this,anchor=null;\n if(mode==='pair'){st.a=parse(fields[0].value);st.b=parse(fields[1].value);}\n var pop=document.createElement('div');pop.className='dp-pop';pop.hidden=true;pop.setAttribute('role','dialog');pop.setAttribute('aria-label','Choose your dates');\n var btns=fields.map(function(inp,k){\n  var w=document.createElement('div');w.className='dp';\n  var b=document.createElement('button');b.type='button';b.className='dp-btn';b.setAttribute('aria-haspopup','dialog');b.setAttribute('aria-expanded','false');\n  if(inp.id){b.id=inp.id;inp.removeAttribute('id');}\n  inp.parentNode.insertBefore(w,inp);w.appendChild(b);w.appendChild(inp);inp.type='hidden';\n  b.addEventListener('click',function(){pop.hidden||anchor!==w?open(w,k):close();});\n  return b;});\n function months(){return window.innerWidth<700?1:2;}\n function cls(d){var c=[];if(d<TODAY)c.push('past');if(+d===+TODAY)c.push('today');\n  var a=st.a,b=st.b||(st.a&&st.hover&&st.hover>st.a?st.hover:null);\n  if(a&&+d===+a)c.push('s');if(b&&+d===+b)c.push('e');if(a&&b&&d>a&&d<b)c.push('in');\n  if(st.a&&nights(st.a,d)===IDEAL)c.push('ideal');return c.join(' ');}\n function draw(){var n=months(),h='<div class=\"dp-head\"><button type=\"button\" class=\"dp-nav dp-prev\" aria-label=\"Previous month\">\u2039<\/button><button type=\"button\" class=\"dp-nav dp-next\" aria-label=\"Next month\">\u203a<\/button><\/div><div class=\"dp-months\">';\n  for(var k=0;k<n;k++){var m=new Date(st.view.getFullYear(),st.view.getMonth()+k,1),first=(m.getDay()+6)%7,days=new Date(m.getFullYear(),m.getMonth()+1,0).getDate();\n   h+='<div class=\"dp-month\"><p class=\"dp-title\">'+MN[m.getMonth()]+' '+m.getFullYear()+'<\/p><div class=\"dp-grid\">'+WD.map(function(w){return '<span class=\"dp-wd\">'+w+'<\/span>';}).join('');\n   for(var i=0;i<first;i++)h+='<span><\/span>';\n   for(var dd=1;dd<=days;dd++){var d=new Date(m.getFullYear(),m.getMonth(),dd),c=cls(d);\n    h+='<button type=\"button\" class=\"dp-day '+c+'\" data-d=\"'+iso(d)+'\"'+(d<TODAY?' disabled':'')+' aria-label=\"'+nice(d)+(\/ideal\/.test(c)?', '+IDEAL+' nights, ideal stay':'')+'\"'+(\/\\b(s|e)\\b\/.test(c)?' aria-pressed=\"true\"':'')+'>'+dd+'<\/button>';}\n   h+='<\/div><\/div>';}\n  var nn=st.a&&st.b?nights(st.a,st.b):0,msg=!st.a?'Select your arrival date. <b>'+IDEAL+' nights<\/b> is the ideal stay for most programmes.':!st.b?'Now select your departure date. 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