{"id":4811,"date":"2022-01-04T11:30:56","date_gmt":"2022-01-04T10:30:56","guid":{"rendered":"https:\/\/microbiome-center.nl\/for-clients\/self-test\/"},"modified":"2022-01-04T11:30:57","modified_gmt":"2022-01-04T10:30:57","slug":"self-test","status":"publish","type":"page","link":"https:\/\/microbiome-center.nl\/en\/for-clients\/self-test\/","title":{"rendered":"Self test"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; admin_label=&#8221;pagina kop&#8221; _builder_version=&#8221;4.9.1&#8243; _module_preset=&#8221;default&#8221; use_background_color_gradient=&#8221;on&#8221; background_color_gradient_start=&#8221;rgba(43,135,218,0)&#8221; background_color_gradient_end=&#8221;#05918f&#8221; background_color_gradient_direction=&#8221;90deg&#8221; background_color_gradient_end_position=&#8221;50%&#8221; background_image=&#8221;https:\/\/microbiome-center.nl\/wp-content\/uploads\/2020\/11\/Start-behandeling-als-patient.jpg&#8221; background_blend=&#8221;multiply&#8221; positioning=&#8221;none&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;0px||0px||false|false&#8221; hover_transition_duration=&#8221;0ms&#8221;][et_pb_row custom_padding_last_edited=&#8221;on|desktop&#8221; _builder_version=&#8221;4.9.1&#8243; _module_preset=&#8221;default&#8221; custom_margin=&#8221;100px|auto|0px|auto|false|false&#8221; custom_margin_tablet=&#8221;50px||||false|false&#8221; custom_margin_phone=&#8221;50px||||false|false&#8221; custom_margin_last_edited=&#8221;on|desktop&#8221; custom_padding=&#8221;100px||100px||false|false&#8221; custom_padding_tablet=&#8221;||50px||false|false&#8221; custom_padding_phone=&#8221;100px||50px||false|false&#8221; hover_transition_duration=&#8221;0ms&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.6.6&#8243; _module_preset=&#8221;default&#8221;][et_pb_text _builder_version=&#8221;4.9.1&#8243; text_font=&#8221;Titillium Web|600|||||||&#8221; text_text_color=&#8221;#ffffff&#8221; text_font_size=&#8221;16px&#8221; text_line_height=&#8221;1.5em&#8221; header_font=&#8221;Titillium Web|700|||||||&#8221; header_text_align=&#8221;left&#8221; header_text_color=&#8221;#ffffff&#8221; header_font_size=&#8221;50px&#8221; header_line_height=&#8221;1.2em&#8221; background_layout=&#8221;dark&#8221; max_width_tablet=&#8221;&#8221; max_width_phone=&#8221;&#8221; max_width_last_edited=&#8221;on|desktop&#8221; custom_margin=&#8221;41px|||||&#8221; custom_margin_tablet=&#8221;0px||||false|false&#8221; custom_margin_phone=&#8221;0px||||false|false&#8221; custom_margin_last_edited=&#8221;on|desktop&#8221; custom_padding=&#8221;|29px||||&#8221; hover_transition_duration=&#8221;0ms&#8221; text_font_size_tablet=&#8221;16px&#8221; text_font_size_phone=&#8221;14px&#8221; text_font_size_last_edited=&#8221;on|phone&#8221; header_font_size_tablet=&#8221;40px&#8221; header_font_size_phone=&#8221;28px&#8221; header_font_size_last_edited=&#8221;on|phone&#8221; locked=&#8221;off&#8221; text_font_size__hover=&#8221;14px&#8221; text_font_size__hover_enabled=&#8221;14px&#8221;]<\/p>\n<h1>Test yourself<\/h1>\n<p>The short test below will give you an initial estimate of the chance of improving your microbiome. Based on this, you can make the decision yourself whether you actually want to do a microbiome analysis.<\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; admin_label=&#8221;client statements&#8221; module_id=&#8221;Complaints&#8221; module_class=&#8221;Klachten&#8221; _builder_version=&#8221;4.9.1&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#f7f5f2&#8243; custom_padding=&#8221;50px||70px|||&#8221; hover_transition_duration=&#8221;0ms&#8221;][et_pb_row use_custom_gutter=&#8221;on&#8221; gutter_width=&#8221;2&#8243; make_equal=&#8221;on&#8221; module_id=&#8221;klachten&#8221; module_class=&#8221;klachten&#8221; _builder_version=&#8221;4.9.1&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#ffffff&#8221; min_height=&#8221;270px&#8221; custom_margin=&#8221;0px|auto||auto||&#8221; custom_padding=&#8221;0px||0px|||&#8221; hover_enabled=&#8221;0&#8243; border_radii=&#8221;off|60px|||&#8221; 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custom_margin=&#8221;0px|auto||auto||&#8221; custom_padding=&#8221;0px||0px|||&#8221; animation_style=&#8221;flip&#8221; border_radii=&#8221;off|||60px|&#8221; box_shadow_style=&#8221;preset3&#8243; box_shadow_vertical=&#8221;32px&#8221; box_shadow_blur=&#8221;55px&#8221; box_shadow_spread=&#8221;-32px&#8221; box_shadow_color=&#8221;rgba(46,38,69,0.54)&#8221;][et_pb_column type=&#8221;1_2&#8243; _builder_version=&#8221;4.6.6&#8243; _module_preset=&#8221;default&#8221;][\/et_pb_column][et_pb_column type=&#8221;1_2&#8243; _builder_version=&#8221;4.6.6&#8243; _module_preset=&#8221;default&#8221;][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Test yourself The short test below will give you an initial estimate of the chance of improving your microbiome. Based on this, you can make the decision yourself whether you actually want to do a microbiome analysis.\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework zelftriage_wrapper' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_7' ><div id='gf_7' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_7' class='zelftriage' action='\/en\/wp-json\/wp\/v2\/pages\/4811#gf_7' data-formid='7' novalidate>\n        <div id='gf_progressbar_wrapper_7' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>4<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_25' style='width:25%;'><span>25%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_7_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_7_11\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_11'>Company<\/label><div class='ginput_container'><input name='input_11' id='input_7_11' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_7_11'>This field is for validation purposes and should be left unchanged.<\/div><\/div><fieldset id=\"field_7_1\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >How are your stools: is there...<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_7_1'><div class='gchoice gchoice_7_1_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_1.1' type='checkbox'  value='Very hard stools \/ constipation'  id='choice_7_1_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_1_1' id='label_7_1_1' class='gform-field-label gform-field-label--type-inline'>Very hard stools \/ constipation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_1_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_1.2' type='checkbox'  value='Very soft stools\/diarrhoea'  id='choice_7_1_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_1_2' id='label_7_1_2' class='gform-field-label gform-field-label--type-inline'>Very soft stools\/diarrhoea<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_1_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_1.3' type='checkbox'  value='Variety - in hard\/soft or in frequency'  id='choice_7_1_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_1_3' id='label_7_1_3' class='gform-field-label gform-field-label--type-inline'>Variety - in hard\/soft or in frequency<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_1_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_1.4' type='checkbox'  value='Greasy sticky stools'  id='choice_7_1_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_1_4' id='label_7_1_4' class='gform-field-label gform-field-label--type-inline'>Greasy sticky stools<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_1_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_1.5' type='checkbox'  value='Visible undigested remains'  id='choice_7_1_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_1_5' id='label_7_1_5' class='gform-field-label gform-field-label--type-inline'>Visible undigested remains<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_1_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_1.6' type='checkbox'  value='Striking stench'  id='choice_7_1_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_1_6' id='label_7_1_6' class='gform-field-label gform-field-label--type-inline'>Striking stench<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_1_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_1.7' type='checkbox'  value='Explosive defecation'  id='choice_7_1_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_1_7' id='label_7_1_7' class='gform-field-label gform-field-label--type-inline'>Explosive defecation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_1_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_1.8' type='checkbox'  value='Mucus in stool'  id='choice_7_1_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_1_8' id='label_7_1_8' class='gform-field-label gform-field-label--type-inline'>Mucus in stool<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_1_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_1.9' type='checkbox'  value='Strongly changing color'  id='choice_7_1_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_1_9' id='label_7_1_9' class='gform-field-label gform-field-label--type-inline'>Strongly changing color<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_7_8' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_2' class='gform_page' data-js='page-field-id-8' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_7_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_7_2\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >How is your belly: do you regularly...<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_7_2'><div class='gchoice gchoice_7_2_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_2.1' type='checkbox'  value='Stomach ache'  id='choice_7_2_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_2_1' id='label_7_2_1' class='gform-field-label gform-field-label--type-inline'>Stomach ache<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_2_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_2.2' type='checkbox'  value='Abdominal cramp'  id='choice_7_2_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_2_2' id='label_7_2_2' class='gform-field-label gform-field-label--type-inline'>Abdominal cramp<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_2_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_2.3' type='checkbox'  value='Flatulence'  id='choice_7_2_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_2_3' id='label_7_2_3' class='gform-field-label gform-field-label--type-inline'>Flatulence<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_2_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_2.4' type='checkbox'  value='Bloated feeling'  id='choice_7_2_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_2_4' id='label_7_2_4' class='gform-field-label gform-field-label--type-inline'>Bloated feeling<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_2_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_2.5' type='checkbox'  value='Feeling full - even though you haven&#039;t eaten much'  id='choice_7_2_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_2_5' id='label_7_2_5' class='gform-field-label gform-field-label--type-inline'>Feeling full - even though you haven't eaten much<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_2_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_2.6' type='checkbox'  value='Bulging belly'  id='choice_7_2_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_2_6' id='label_7_2_6' class='gform-field-label gform-field-label--type-inline'>Bulging belly<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_2_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_2.7' type='checkbox'  value='Empty urge to poop'  id='choice_7_2_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_2_7' id='label_7_2_7' class='gform-field-label gform-field-label--type-inline'>Empty urge to poop<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_2_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_2.8' type='checkbox'  value='Rumbling in the stomach, collywobbles'  id='choice_7_2_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_2_8' id='label_7_2_8' class='gform-field-label gform-field-label--type-inline'>Rumbling in the stomach, collywobbles<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_2_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_2.9' type='checkbox'  value='Abdominal pain after eating'  id='choice_7_2_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_2_9' id='label_7_2_9' class='gform-field-label gform-field-label--type-inline'>Abdominal pain after eating<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_2_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_2.11' type='checkbox'  value='Hungry quickly after eating'  id='choice_7_2_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_2_11' id='label_7_2_11' class='gform-field-label gform-field-label--type-inline'>Hungry quickly after eating<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_2_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_2.12' type='checkbox'  value='Belching \/ burping'  id='choice_7_2_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_2_12' id='label_7_2_12' class='gform-field-label gform-field-label--type-inline'>Belching \/ burping<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_2_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_2.13' type='checkbox'  value='Heartburn'  id='choice_7_2_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_2_13' id='label_7_2_13' class='gform-field-label gform-field-label--type-inline'>Heartburn<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_2_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_2.14' type='checkbox'  value='Nausea'  id='choice_7_2_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_2_14' id='label_7_2_14' class='gform-field-label gform-field-label--type-inline'>Nausea<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_7_9' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_7_9' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_3' class='gform_page' data-js='page-field-id-9' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_7_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_7_3\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >How is your energy and mood? Do you ever have incomprehensible...<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_7_3'><div class='gchoice gchoice_7_3_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.1' type='checkbox'  value='Fatigue'  id='choice_7_3_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_3_1' id='label_7_3_1' class='gform-field-label gform-field-label--type-inline'>Fatigue<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_3_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.2' type='checkbox'  value='Shortness of breath'  id='choice_7_3_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_3_2' id='label_7_3_2' class='gform-field-label gform-field-label--type-inline'>Shortness of breath<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_3_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.3' type='checkbox'  value='Gloom'  id='choice_7_3_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_3_3' id='label_7_3_3' class='gform-field-label gform-field-label--type-inline'>Gloom<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_3_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.4' type='checkbox'  value='Moods'  id='choice_7_3_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_3_4' id='label_7_3_4' class='gform-field-label gform-field-label--type-inline'>Moods<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_3_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.5' type='checkbox'  value='Feelings of anxiety or stress'  id='choice_7_3_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_3_5' id='label_7_3_5' class='gform-field-label gform-field-label--type-inline'>Feelings of anxiety or stress<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_3_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.6' type='checkbox'  value='Concentration or memory problems'  id='choice_7_3_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_3_6' id='label_7_3_6' class='gform-field-label gform-field-label--type-inline'>Concentration or memory problems<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_7_10' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_7_10' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_4' class='gform_page' data-js='page-field-id-10' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_7_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_7_4\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you have long-term complaints or a chronic illness?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_7_4'><div class='gchoice gchoice_7_4_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.1' type='checkbox'  value='Lactose- of gluten intolerantie'  id='choice_7_4_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_4_1' id='label_7_4_1' class='gform-field-label gform-field-label--type-inline'>Lactose- of gluten 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gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_4_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.5' type='checkbox'  value='Cardiovascular complaints'  id='choice_7_4_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_4_5' id='label_7_4_5' class='gform-field-label gform-field-label--type-inline'>Cardiovascular complaints<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_4_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.6' type='checkbox'  value='Respiratory problems'  id='choice_7_4_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_4_6' id='label_7_4_6' class='gform-field-label gform-field-label--type-inline'>Respiratory problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_4_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.7' type='checkbox'  value='Urinary issues'  id='choice_7_4_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_4_7' 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