{"id":4609,"date":"2021-06-28T09:08:20","date_gmt":"2021-06-28T09:08:20","guid":{"rendered":"https:\/\/www.stimezo-zwolle.nl\/anamneseformulier\/"},"modified":"2023-12-20T14:58:50","modified_gmt":"2023-12-20T14:58:50","slug":"%d8%b4%d9%83%d9%84-%d8%a7%d9%84%d8%aa%d8%a7%d8%b1%d9%8a%d8%ae","status":"publish","type":"page","link":"https:\/\/www.stimezo-zwolle.nl\/ar\/%d8%b4%d9%83%d9%84-%d8%a7%d9%84%d8%aa%d8%a7%d8%b1%d9%8a%d8%ae\/","title":{"rendered":"\u0634\u0643\u0644 \u0627\u0644\u062a\u0627\u0631\u064a\u062e"},"content":{"rendered":"<!--themify_builder_content-->\n<div id=\"themify_builder_content-4609\" data-postid=\"4609\" class=\"themify_builder_content themify_builder_content-4609 themify_builder tf_clear\">\n                    <div  data-css_id=\"kx75846\" data-lazy=\"1\" class=\"module_row themify_builder_row fullheight fullwidth_row_container tb_kx75846 tb_first tf_w\">\n                        <div class=\"row_inner col_align_top tb_col_count_2 tf_box tf_rel\">\n                        <div  data-lazy=\"1\" class=\"module_column tb-column col4-2 tb_381h356 first\">\n                    <!-- module text -->\n<div  class=\"module module-text tb_01sd357   \" data-lazy=\"1\">\n        <div  class=\"tb_text_wrap\">\n        <h1>\u0634\u0643\u0644 \u0627\u0644\u062a\u0627\u0631\u064a\u062e<\/h1>    <\/div>\n<\/div>\n<!-- \/module text -->        <\/div>\n                    <div  data-lazy=\"1\" class=\"module_column tb-column col4-2 tb_2z9c854 last\">\n                            <\/div>\n                        <\/div>\n        <\/div>\n                        <div  data-css_id=\"st49848\" data-lazy=\"1\" class=\"module_row themify_builder_row fullwidth_row_container tb_st49848 tf_w\">\n                        <div class=\"row_inner col_align_top tb_col_count_1 tf_box tf_rel\">\n                        <div  data-lazy=\"1\" class=\"module_column tb-column col-full tb_n0gu858 first\">\n                    <!-- module text -->\n<div  class=\"module module-text tb_068q858   \" data-lazy=\"1\">\n        <div  class=\"tb_text_wrap\">\n        <h3>\u0627\u0645\u0644\u0623 \u0646\u0645\u0648\u0630\u062c \u0627\u0644\u0623\u0633\u0626\u0644\u0629 \u0639\u0628\u0631 \u0627\u0644\u0625\u0646\u062a\u0631\u0646\u062a \u0623\u062f\u0646\u0627\u0647.<\/h3>\n<p>\u00a0<\/p>\n<p>\u062a\u064f\u0639\u0627\u0644\u062c \u0639\u064a\u0627\u062f\u0629 \u0627\u0644\u0625\u062c\u0647\u0627\u0636 Stimezo Zwolle \u0628\u064a\u0627\u0646\u0627\u062a\u0643\u0650 \u0628\u0639\u0646\u0627\u064a\u0629.<\/p>\n<p>\u00a0<\/p>    <\/div>\n<\/div>\n<!-- \/module text --><!-- module plain text -->\n<div  class=\"module module-plain-text tb_9hba765 \" data-lazy=\"1\">\n        <div class=\"tb_text_wrap\">\n    <form method=\"post\" enctype=\"multipart\/form-data\" id=\"vfbp-form-25\" class=\"vfbp-form\"><div style=\"display:none;\"><label for=\"vfbp-EMAIL-AN8fuQyoDLXem\">If you are human, leave this field blank.<\/label><input size=\"25\" autocomplete=\"off\" type=\"text\" name=\"vfbp-EMAIL-AN8fuQyoDLXem\" value=\"\" id=\"\"><\/div><input type=\"hidden\" name=\"_vfb-timestamp-25\" value=\"1781909615\" id=\"\"><input type=\"hidden\" name=\"_vfb-form-id\" value=\"25\" id=\"\"><div class=\"vfb-well vfb-col-12\" id=\"vfbField1368\"><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\"><\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField1368\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-checkbox\" id=\"vfbField1369\"><label for=\"vfb-field-1369\" class=\"vfb-control-label\">Link ontvangen formulier?  <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u0648\u0635\u0644\u0643\u0650 \u0631\u0627\u0628\u0637 \u0645\u0646\u0627 \u0644\u0645\u0644\u0621 \u0647\u0630\u0627 \u0627\u0644\u0646\u0645\u0648\u0630\u062c\u061f<\/span><div class=\"vfb-inline-group\"><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1369-0\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1369\" required=\"required\" type=\"checkbox\" name=\"vfb-field-1369[0]\" value=\"1\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1369-1\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1369\" type=\"checkbox\" name=\"vfb-field-1369[1]\" value=\"1\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-date\" id=\"vfbField1370\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1370\" class=\"vfb-control-label\">Datum afspraak? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0625\u0630\u0627 \u0643\u0627\u0646\u062a \u0627\u0644\u0625\u062c\u0627\u0628\u0629 \"\u0646\u0639\u0645\"\u060c \u0641\u0645\u0627 \u0647\u0648 \u062a\u0627\u0631\u064a\u062e \u0645\u0648\u0639\u062f\u0643\u0650 \u0639\u0646\u062f\u0646\u0627\u061f<\/span><input id=\"vfb-field-1370\" class=\"vfb-form-control\" placeholder=\"\u0645\u0648\u0639\u062f \u0627\u0644\u0645\u0648\u0639\u062f\" required=\"required\" data-provide=\"datepicker\" data-date-format=\"dd\/mm\/yyyy\" data-date-language=\"nl\" type=\"text\" name=\"vfb-field-1370\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-col-6 vfb-fieldType-text\" id=\"vfbField1467\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1467\" class=\"vfb-control-label\">Tijd afspraak? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0641\u064a \u0623\u064a \u0648\u0642\u062a \u0644\u062f\u064a\u0643 \u0645\u0648\u0639\u062f \u0645\u0639\u0646\u0627\u061f<\/span><input id=\"vfb-field-1467\" class=\"vfb-form-control\" placeholder=\"(\u0639\u0644\u0649 \u0633\u0628\u064a\u0644 \u0627\u0644\u0645\u062b\u0627\u0644 08:00)\" required=\"required\" type=\"text\" name=\"vfb-field-1467\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><\/div> <!-- .vfb-well --><div class=\"vfb-well vfb-col-12\" id=\"vfbField1371\"><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\"><\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField1371\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-text\" id=\"vfbField1372\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1372\" class=\"vfb-control-label\">Naam <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1372\" class=\"vfb-form-control\" placeholder=\"\u0627\u0644\u0627\u0633\u0645 \u0627\u0644\u0634\u062e\u0635\u064a \u0648\u0627\u0644\u0627\u0633\u0645 \u0627\u0644\u0639\u0627\u0626\u0644\u064a\" required=\"required\" type=\"text\" name=\"vfb-field-1372\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-col-6 vfb-fieldType-email\" id=\"vfbField1373\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1373\" class=\"vfb-control-label\">E-mail <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1373\" class=\"vfb-form-control\" placeholder=\"\u0639\u0646\u0648\u0627\u0646 \u0627\u0644\u0628\u0631\u064a\u062f \u0627\u0644\u0625\u0644\u0643\u062a\u0631\u0648\u0646\u064a\" required=\"required\" type=\"email\" name=\"vfb-field-1373\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-date\" id=\"vfbField1374\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1374\" class=\"vfb-control-label\">Geboortedatum <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1374\" class=\"vfb-form-control\" placeholder=\"\u062a\u0627\u0631\u064a\u062e \u0627\u0644\u0645\u064a\u0644\u0627\u062f \" required=\"required\" data-provide=\"datepicker\" data-date-format=\"dd\/mm\/yyyy\" data-date-language=\"nl\" type=\"text\" name=\"vfb-field-1374\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-col-6 vfb-fieldType-select\" id=\"vfbField1375\"><label for=\"vfb-field-1375\" class=\"vfb-control-label\">Geboorteland <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><div class=\"vfb-form-group\"><select id=\"vfb-field-1375\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" name=\"vfb-field-1375\"><option value=\"\u0628\u0644\u062f \u0627\u0644\u0645\u064a\u0644\u0627\u062f\">\u0628\u0644\u062f \u0627\u0644\u0645\u064a\u0644\u0627\u062f<\/option><option value=\"Nederland\">Nederland<\/option><option value=\"Afghanistan\">Afghanistan<\/option><option value=\"&Aring;land Islands\">\u00c5land Islands<\/option><option value=\"Albania\">Albania<\/option><option value=\"Algeria\">Algeria<\/option><option value=\"Andorra\">Andorra<\/option><option value=\"Angola\">Angola<\/option><option value=\"Anguilla\">Anguilla<\/option><option value=\"Antarctica\">Antarctica<\/option><option value=\"Antigua and Barbuda\">Antigua and Barbuda<\/option><option value=\"Argentina\">Argentina<\/option><option value=\"Armenia\">Armenia<\/option><option value=\"Aruba\">Aruba<\/option><option value=\"American Samoa\">American Samoa<\/option><option value=\"Australia\">Australia<\/option><option value=\"Austria\">Austria<\/option><option value=\"Azerbaijan\">Azerbaijan<\/option><option value=\"Bahamas\">Bahamas<\/option><option value=\"Bahrain\">Bahrain<\/option><option value=\"Bangladesh\">Bangladesh<\/option><option value=\"Barbados\">Barbados<\/option><option value=\"Belarus\">Belarus<\/option><option value=\"Belgium\">Belgium<\/option><option value=\"Belau\">Belau<\/option><option value=\"Belize\">Belize<\/option><option value=\"Benin\">Benin<\/option><option value=\"Bermuda\">Bermuda<\/option><option value=\"Bhutan\">Bhutan<\/option><option value=\"Bolivia\">Bolivia<\/option><option value=\"Bonaire, Saint Eustatius and Saba\">Bonaire, Saint Eustatius and Saba<\/option><option value=\"Bosnia and Herzegovina\">Bosnia and Herzegovina<\/option><option value=\"Botswana\">Botswana<\/option><option value=\"Bouvet Island\">Bouvet Island<\/option><option value=\"Brazil\">Brazil<\/option><option value=\"British Indian Ocean Territory\">British Indian Ocean Territory<\/option><option value=\"British Virgin Islands\">British Virgin Islands<\/option><option value=\"Brunei\">Brunei<\/option><option value=\"Bulgaria\">Bulgaria<\/option><option value=\"Burkina Faso\">Burkina Faso<\/option><option value=\"Burundi\">Burundi<\/option><option value=\"Cambodia\">Cambodia<\/option><option value=\"Cameroon\">Cameroon<\/option><option value=\"Canada\">Canada<\/option><option value=\"Cape Verde\">Cape Verde<\/option><option value=\"Cayman Islands\">Cayman Islands<\/option><option value=\"Central African Republic\">Central African Republic<\/option><option value=\"Chad\">Chad<\/option><option value=\"Chile\">Chile<\/option><option value=\"China\">China<\/option><option value=\"Christmas Island\">Christmas Island<\/option><option value=\"Cocos (Keeling) Islands\">Cocos (Keeling) Islands<\/option><option value=\"Colombia\">Colombia<\/option><option value=\"Comoros\">Comoros<\/option><option value=\"Congo (Brazzaville)\">Congo (Brazzaville)<\/option><option value=\"Congo (Kinshasa)\">Congo (Kinshasa)<\/option><option value=\"Cook Islands\">Cook Islands<\/option><option value=\"Costa Rica\">Costa Rica<\/option><option value=\"Croatia\">Croatia<\/option><option value=\"Cuba\">Cuba<\/option><option value=\"Cura&Ccedil;ao\">Cura\u00c7ao<\/option><option value=\"Cyprus\">Cyprus<\/option><option value=\"Czech Republic\">Czech Republic<\/option><option value=\"Denmark\">Denmark<\/option><option value=\"Djibouti\">Djibouti<\/option><option value=\"Dominica\">Dominica<\/option><option value=\"Dominican Republic\">Dominican Republic<\/option><option value=\"Ecuador\">Ecuador<\/option><option value=\"Egypt\">Egypt<\/option><option value=\"El Salvador\">El Salvador<\/option><option value=\"Equatorial Guinea\">Equatorial Guinea<\/option><option value=\"Eritrea\">Eritrea<\/option><option value=\"Estonia\">Estonia<\/option><option value=\"Ethiopia\">Ethiopia<\/option><option value=\"Falkland Islands\">Falkland Islands<\/option><option value=\"Faroe Islands\">Faroe Islands<\/option><option value=\"Fiji\">Fiji<\/option><option value=\"Finland\">Finland<\/option><option value=\"France\">France<\/option><option value=\"French Guiana\">French Guiana<\/option><option value=\"French Polynesia\">French Polynesia<\/option><option value=\"French Southern Territories\">French Southern Territories<\/option><option value=\"Gabon\">Gabon<\/option><option value=\"Gambia\">Gambia<\/option><option value=\"Georgia\">Georgia<\/option><option value=\"Germany\">Germany<\/option><option value=\"Ghana\">Ghana<\/option><option value=\"Gibraltar\">Gibraltar<\/option><option value=\"Greece\">Greece<\/option><option value=\"Greenland\">Greenland<\/option><option value=\"Grenada\">Grenada<\/option><option value=\"Guadeloupe\">Guadeloupe<\/option><option value=\"Guatemala\">Guatemala<\/option><option value=\"Guernsey\">Guernsey<\/option><option value=\"Guinea\">Guinea<\/option><option value=\"Guinea-Bissau\">Guinea-Bissau<\/option><option value=\"Guyana\">Guyana<\/option><option value=\"Haiti\">Haiti<\/option><option value=\"Heard Island and McDonald Islands\">Heard Island and McDonald Islands<\/option><option value=\"Honduras\">Honduras<\/option><option value=\"Hong Kong\">Hong Kong<\/option><option value=\"Hungary\">Hungary<\/option><option value=\"Iceland\">Iceland<\/option><option value=\"India\">India<\/option><option value=\"Indonesia\">Indonesia<\/option><option value=\"Iran\">Iran<\/option><option value=\"Iraq\">Iraq<\/option><option value=\"Republic of Ireland\">Republic of Ireland<\/option><option value=\"Isle of Man\">Isle of Man<\/option><option value=\"Israel\">Israel<\/option><option value=\"Italy\">Italy<\/option><option value=\"Ivory Coast\">Ivory Coast<\/option><option value=\"Jamaica\">Jamaica<\/option><option value=\"Japan\">Japan<\/option><option value=\"Jersey\">Jersey<\/option><option value=\"Jordan\">Jordan<\/option><option value=\"Kazakhstan\">Kazakhstan<\/option><option value=\"Kenya\">Kenya<\/option><option value=\"Kiribati\">Kiribati<\/option><option value=\"Kuwait\">Kuwait<\/option><option value=\"Kyrgyzstan\">Kyrgyzstan<\/option><option value=\"Laos\">Laos<\/option><option value=\"Latvia\">Latvia<\/option><option value=\"Lebanon\">Lebanon<\/option><option value=\"Lesotho\">Lesotho<\/option><option value=\"Liberia\">Liberia<\/option><option value=\"Libya\">Libya<\/option><option value=\"Liechtenstein\">Liechtenstein<\/option><option value=\"Lithuania\">Lithuania<\/option><option value=\"Luxembourg\">Luxembourg<\/option><option value=\"Macao S.A.R., China\">Macao S.A.R., China<\/option><option value=\"Macedonia\">Macedonia<\/option><option value=\"Madagascar\">Madagascar<\/option><option value=\"Malawi\">Malawi<\/option><option value=\"Malaysia\">Malaysia<\/option><option value=\"Maldives\">Maldives<\/option><option value=\"Mali\">Mali<\/option><option value=\"Malta\">Malta<\/option><option value=\"Marshall Islands\">Marshall Islands<\/option><option value=\"Martinique\">Martinique<\/option><option value=\"Mauritania\">Mauritania<\/option><option value=\"Mauritius\">Mauritius<\/option><option value=\"Mayotte\">Mayotte<\/option><option value=\"Mexico\">Mexico<\/option><option value=\"Micronesia\">Micronesia<\/option><option value=\"Moldova\">Moldova<\/option><option value=\"Monaco\">Monaco<\/option><option value=\"Mongolia\">Mongolia<\/option><option value=\"Montenegro\">Montenegro<\/option><option value=\"Montserrat\">Montserrat<\/option><option value=\"Morocco\">Morocco<\/option><option value=\"Mozambique\">Mozambique<\/option><option value=\"Myanmar\">Myanmar<\/option><option value=\"Namibia\">Namibia<\/option><option value=\"Nauru\">Nauru<\/option><option value=\"Nepal\">Nepal<\/option><option value=\"Netherlands Antilles\">Netherlands Antilles<\/option><option value=\"New Caledonia\">New Caledonia<\/option><option value=\"New Zealand\">New Zealand<\/option><option value=\"Nicaragua\">Nicaragua<\/option><option value=\"Niger\">Niger<\/option><option value=\"Nigeria\">Nigeria<\/option><option value=\"Niue\">Niue<\/option><option value=\"Norfolk Island\">Norfolk Island<\/option><option value=\"North Korea\">North Korea<\/option><option value=\"Norway\">Norway<\/option><option value=\"Oman\">Oman<\/option><option value=\"Pakistan\">Pakistan<\/option><option value=\"Palestinian Territory\">Palestinian Territory<\/option><option value=\"Panama\">Panama<\/option><option value=\"Papua New Guinea\">Papua New Guinea<\/option><option value=\"Paraguay\">Paraguay<\/option><option value=\"Peru\">Peru<\/option><option value=\"Philippines\">Philippines<\/option><option value=\"Pitcairn\">Pitcairn<\/option><option value=\"Poland\">Poland<\/option><option value=\"Portugal\">Portugal<\/option><option value=\"Qatar\">Qatar<\/option><option value=\"Reunion\">Reunion<\/option><option value=\"Romania\">Romania<\/option><option value=\"Russia\">Russia<\/option><option value=\"Rwanda\">Rwanda<\/option><option value=\"Saint Barth&eacute;lemy\">Saint Barth\u00e9lemy<\/option><option value=\"Saint Helena\">Saint Helena<\/option><option value=\"Saint Kitts and Nevis\">Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\">Saint Lucia<\/option><option value=\"Saint Martin (French part)\">Saint Martin (French part)<\/option><option value=\"Saint Martin (Dutch part)\">Saint Martin (Dutch part)<\/option><option value=\"Saint Pierre and Miquelon\">Saint Pierre and Miquelon<\/option><option value=\"Saint Vincent and the Grenadines\">Saint Vincent and the Grenadines<\/option><option value=\"San Marino\">San Marino<\/option><option value=\"S&atilde;o Tom&eacute; and Pr&iacute;ncipe\">S\u00e3o Tom\u00e9 and Pr\u00edncipe<\/option><option value=\"Saudi Arabia\">Saudi Arabia<\/option><option value=\"Senegal\">Senegal<\/option><option value=\"Serbia\">Serbia<\/option><option value=\"Seychelles\">Seychelles<\/option><option value=\"Sierra Leone\">Sierra Leone<\/option><option value=\"Singapore\">Singapore<\/option><option value=\"Slovakia\">Slovakia<\/option><option value=\"Slovenia\">Slovenia<\/option><option value=\"Solomon Islands\">Solomon Islands<\/option><option value=\"Somalia\">Somalia<\/option><option value=\"South Africa\">South Africa<\/option><option value=\"South Georgia\/Sandwich Islands\">South Georgia\/Sandwich Islands<\/option><option value=\"South Korea\">South Korea<\/option><option value=\"South Sudan\">South Sudan<\/option><option value=\"Spain\">Spain<\/option><option value=\"Sri Lanka\">Sri Lanka<\/option><option value=\"Sudan\">Sudan<\/option><option value=\"Suriname\">Suriname<\/option><option value=\"Svalbard and Jan Mayen\">Svalbard and Jan Mayen<\/option><option value=\"Swaziland\">Swaziland<\/option><option value=\"Sweden\">Sweden<\/option><option value=\"Switzerland\">Switzerland<\/option><option value=\"Syria\">Syria<\/option><option value=\"Taiwan\">Taiwan<\/option><option value=\"Tajikistan\">Tajikistan<\/option><option value=\"Tanzania\">Tanzania<\/option><option value=\"Thailand\">Thailand<\/option><option value=\"Timor-Leste\">Timor-Leste<\/option><option value=\"Togo\">Togo<\/option><option value=\"Tokelau\">Tokelau<\/option><option value=\"Tonga\">Tonga<\/option><option value=\"Trinidad and Tobago\">Trinidad and Tobago<\/option><option value=\"Tunisia\">Tunisia<\/option><option value=\"Turkey\">Turkey<\/option><option value=\"Turkmenistan\">Turkmenistan<\/option><option value=\"Turks and Caicos Islands\">Turks and Caicos Islands<\/option><option value=\"Tuvalu\">Tuvalu<\/option><option value=\"Uganda\">Uganda<\/option><option value=\"Ukraine\">Ukraine<\/option><option value=\"United Arab Emirates\">United Arab Emirates<\/option><option value=\"United Kingdom (UK)\">United Kingdom (UK)<\/option><option value=\"United States (US)\">United States (US)<\/option><option value=\"Uruguay\">Uruguay<\/option><option value=\"Uzbekistan\">Uzbekistan<\/option><option value=\"Vanuatu\">Vanuatu<\/option><option value=\"Vatican\">Vatican<\/option><option value=\"Venezuela\">Venezuela<\/option><option value=\"Vietnam\">Vietnam<\/option><option value=\"Wallis and Futuna\">Wallis and Futuna<\/option><option value=\"Western Sahara\">Western Sahara<\/option><option value=\"Western Samoa\">Western Samoa<\/option><option value=\"Yemen\">Yemen<\/option><option value=\"Zambia\">Zambia<\/option><option value=\"Zimbabwe\">Zimbabwe<\/option><\/select><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-4 vfb-fieldType-text\" id=\"vfbField1376\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1376\" class=\"vfb-control-label\">Leeftijd <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1376\" class=\"vfb-form-control\" placeholder=\"\u0627\u0644\u0639\u0645\u0631\" required=\"required\" type=\"text\" name=\"vfb-field-1376\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-col-4 vfb-fieldType-text\" id=\"vfbField1377\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1377\" class=\"vfb-control-label\">Lengte  <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1377\" class=\"vfb-form-control\" placeholder=\"\u0627\u0644\u0637\u0648\u0644 (\u0628\u0627\u0644\u0633\u0646\u062a\u064a\u0645\u062a\u0631)\" required=\"required\" type=\"text\" name=\"vfb-field-1377\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-col-4 vfb-fieldType-text\" id=\"vfbField1378\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1378\" class=\"vfb-control-label\">Gewicht <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1378\" class=\"vfb-form-control\" placeholder=\"\u0627\u0644\u0648\u0632\u0646 (\u0628\u0627\u0644\u0643\u064a\u0644\u0648\u062c\u0631\u0627\u0645) \" required=\"required\" type=\"text\" name=\"vfb-field-1378\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-checkbox\" id=\"vfbField1379\"><label for=\"vfb-field-1379\" class=\"vfb-control-label\">Je bent...<\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u0623\u0646\u062a\u0650<\/span><div class=\"vfb-inline-group\"><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1379-0\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1379\" type=\"checkbox\" name=\"vfb-field-1379[0]\" value=\"1\">\u0645\u062a\u0632\u0648\u062c\u0629 \u0623\u0648 \u0645\u064f\u0633\u062c\u0644\u0629 \u0643\u0634\u0631\u064a\u0643\u0629 \u0645\u064f\u0639\u0627\u0634\u0631\u0629 (gehuwd\/geregistreerd partner)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1379-1\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1379\" type=\"checkbox\" name=\"vfb-field-1379[1]\" value=\"1\">\u063a\u064a\u0631 \u0645\u062a\u0632\u0648\u062c\u0629 \u0648\u062a\u0639\u064a\u0634\u064a\u0646 \u0645\u0639 \u0634\u0631\u064a\u0643 \u062d\u064a\u0627\u062a\u0643\u0650 (ongehuwd met partner)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1379-2\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1379\" type=\"checkbox\" name=\"vfb-field-1379[2]\" value=\"1\">\u0639\u0632\u0628\u0627\u0621 (alleenstaand)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1380\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1380\" class=\"vfb-control-label\">Naam huisarts\/huisartsenpraktijk?  <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0645\u0627 \u0647\u0648 \u0627\u0633\u0645 \u0637\u0628\u064a\u0628 \u0627\u0644\u0623\u0633\u0631\u0629 \u0627\u0644\u062e\u0627\u0635 \u0628\u0643\u0650 \u0623\u0648 \u0639\u064a\u0627\u062f\u0629 \u0637\u0628\u064a\u0628 \u0627\u0644\u0623\u0633\u0631\u0629\u061f <\/span><input id=\"vfb-field-1380\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-1380\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-radio\" id=\"vfbField1381\"><label for=\"vfb-field-1381\" class=\"vfb-control-label\">Eerste gesprek huisarts \/ specialist \/ andere arts? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062d\u0636\u0631\u062a\u0650 \u0645\u064f\u0642\u0627\u0628\u0644\u0629 \u0623\u0648\u0651\u064e\u0644\u064a\u0629 \u0645\u0639 \u0637\u0628\u064a\u0628 \u0627\u0644\u0623\u0633\u0631\u0629 \u0623\u0648 \u0627\u062e\u062a\u0635\u0627\u0635\u064a \u0623\u0648 \u0637\u0628\u064a\u0628 \u0622\u062e\u0631 \u0628\u062e\u0635\u0648\u0635 \u0637\u0644\u0628 \u0627\u0644\u0625\u062c\u0647\u0627\u0636 \u0627\u0644\u062e\u0627\u0635 \u0628\u0643\u0650\u061f<\/span><div class=\"vfb-radio\"><label><input id=\"vfb-field-1381-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1381\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1381-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1381\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><div class=\"vfb-col-6 vfb-fieldType-date\" id=\"vfbField1382\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1382\" class=\"vfb-control-label\">Datum eerste gesprek huisarts, specialist of andere arts<\/label><div><span class=\"vfb-help-block\">\u0645\u0627 \u0647\u0648 \u062a\u0627\u0631\u064a\u062e \u0627\u0644\u0645\u0642\u0627\u0628\u0644\u0629 \u0645\u0639 \u0637\u0628\u064a\u0628 \u0627\u0644\u0623\u0633\u0631\u0629 \u0623\u0648 \u0637\u0628\u064a\u0628 \u0622\u062e\u0631 \u0641\u064a\u0645\u0627 \u064a\u062a\u0639\u0644\u0642 \u0628\u0637\u0644\u0628 \u0627\u0644\u0625\u062c\u0647\u0627\u0636\u061f<\/span><input id=\"vfb-field-1382\" class=\"vfb-form-control\" placeholder=\"\" data-provide=\"datepicker\" data-date-format=\"dd\/mm\/yyyy\" data-date-language=\"nl\" type=\"text\" name=\"vfb-field-1382\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-radio\" id=\"vfbField1383\"><label for=\"vfb-field-1383\" class=\"vfb-control-label\">Eerste dag van de laatste menstruatie bekend? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u0639\u0644\u0645\u064a\u0646 \u0645\u062a\u0649 \u0643\u0627\u0646 \u0623\u0648\u0644 \u064a\u0648\u0645 \u0645\u0646 \u0622\u062e\u0631 \u062f\u0648\u0631\u0629 \u0634\u0647\u0631\u064a\u0629\u061f <\/span><div class=\"vfb-radio\"><label><input id=\"vfb-field-1383-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1383\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1383-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1383\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-date\" id=\"vfbField1384\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1384\" class=\"vfb-control-label\">Eerste dag van laatste menstruatie? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u062a\u0627\u0631\u064a\u062e \u0622\u062e\u0631 \u062f\u0648\u0631\u0629 \u0634\u0647\u0631\u064a\u0629<\/span><input id=\"vfb-field-1384\" class=\"vfb-form-control minhoogte\" placeholder=\"\" required=\"required\" data-provide=\"datepicker\" data-date-format=\"dd\/mm\/yyyy\" data-date-start-view=\"1\" data-date-language=\"nl\" type=\"text\" name=\"vfb-field-1384\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><\/div> <!-- .vfb-well --><div class=\"vfb-well vfb-col-12\" id=\"vfbField1385\"><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\"><\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField1385\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-radio\" id=\"vfbField1386\"><label for=\"vfb-field-1386\" class=\"vfb-control-label\">Regelmatig ongesteld? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062f\u0648\u0631\u062a\u0643\u0650 \u0627\u0644\u0634\u0647\u0631\u064a\u0629 \u0645\u0646\u062a\u0638\u0645\u0629\u061f<\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1386-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1386\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1386-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1386\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-col-6 vfb-fieldType-text\" id=\"vfbField1387\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1387\" class=\"vfb-control-label\">Hoeveel dagen bloedverlies?  <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0643\u0645 \u064a\u0648\u0645 \u064a\u0633\u062a\u0645\u0631 \u0641\u0642\u062f\u0627\u0646 \u0627\u0644\u062f\u0645 \u062e\u0644\u0627\u0644 \u062f\u0648\u0631\u062a\u0643\u0650 \u0627\u0644\u0634\u0647\u0631\u064a\u0629\u061f<\/span><input id=\"vfb-field-1387\" class=\"vfb-form-control\" placeholder=\"\u0639\u062f\u062f \u0627\u0644\u0623\u064a\u0627\u0645\" required=\"required\" type=\"text\" name=\"vfb-field-1387\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-radio\" id=\"vfbField1388\"><label for=\"vfb-field-1388\" class=\"vfb-control-label\">Pijn tijdens ongesteldheid?<\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u0639\u0627\u0646\u064a\u0646 \u0645\u0646 \u0623\u0644\u0645 \u0623\u062b\u0646\u0627\u0621 \u0627\u0644\u062f\u0648\u0631\u0629 \u0627\u0644\u0634\u0647\u0631\u064a\u0629\u061f <\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1388-0\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1388\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1388-1\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1388\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-col-3 vfb-fieldType-radio\" id=\"vfbField1389\"><label for=\"vfb-field-1389\" class=\"vfb-control-label\">Houdt u bedrust?<\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u0628\u0642\u064a\u0646 \u0641\u064a \u0627\u0644\u0633\u0631\u064a\u0631 \u0639\u0646\u062f\u0626\u0630\u061f <\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1389-0\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1389\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1389-1\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1389\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-col-3 vfb-fieldType-radio\" id=\"vfbField1390\"><label for=\"vfb-field-1390\" class=\"vfb-control-label\">Gebruikt u pijnstillers?<\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u0633\u062a\u062e\u062f\u0645\u064a\u0646 \u0645\u0633\u0643\u0646\u0627\u062a \u0627\u0644\u0623\u0644\u0645 \u0639\u0646\u062f\u0626\u0630\u061f <\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1390-0\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1390\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1390-1\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1390\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-radio\" id=\"vfbField1391\"><label for=\"vfb-field-1391\" class=\"vfb-control-label\">Eerder zwanger geweest? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u0633\u0628\u0642 \u0644\u0643\u0650 \u0627\u0644\u062d\u0645\u0644 \u0645\u0646 \u0642\u0628\u0644\u061f <\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1391-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1391\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1391-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1391\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-col-6 vfb-fieldType-text\" id=\"vfbField1392\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1392\" class=\"vfb-control-label\">Hoeveel kinderen heeft u? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0643\u0645 \u0639\u062f\u062f \u0627\u0644\u0623\u0637\u0641\u0627\u0644 \u0644\u062f\u064a\u0643\u061f<\/span><input id=\"vfb-field-1392\" class=\"vfb-form-control\" placeholder=\"\u0639\u062f\u062f \u0627\u0644\u0623\u0637\u0641\u0627\u0644 \" required=\"required\" type=\"text\" name=\"vfb-field-1392\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField1393\"><label for=\"vfb-field-1393\" class=\"vfb-control-label\">Problemen bij zwangerschap(pen) \/ bevalling(en)? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u0639\u0627\u0646\u064a\u062a\u0650 \u0645\u0646 \u0623\u064a \u0645\u0634\u0643\u0644\u0627\u062a \u0641\u064a \u0645\u0631\u0629 \u0623\u0648 \u0645\u0631\u0627\u062a \u0627\u0644\u062d\u0645\u0644 \u0648\u0627\u0644\u0648\u0644\u0627\u062f\u0629 \u0627\u0644\u0633\u0627\u0628\u0642\u0629\u061f <\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1393-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1393\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1393-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1393\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-textarea\" id=\"vfbField1394\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1394\" class=\"vfb-control-label\">Toelichting<\/label><div><span class=\"vfb-help-block\">\u0625\u0630\u0627 \u0643\u0627\u0646\u062a \u0627\u0644\u0625\u062c\u0627\u0628\u0629 \u201c\u0646\u0639\u0645\u201d\u060c \u0647\u0644 \u062a\u0631\u064a\u062f\u064a\u0646 \u0627\u0644\u062a\u0639\u0644\u064a\u0642 \u0639\u0644\u0649 \u0630\u0644\u0643\u061f<\/span><textarea id=\"vfb-field-1394\" class=\"vfb-form-control\" placeholder=\"\" rows=\"5\" name=\"vfb-field-1394\" cols=\"50\"><\/textarea><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-radio\" id=\"vfbField1395\"><label for=\"vfb-field-1395\" class=\"vfb-control-label\">Borstvoeding?<\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u0642\u0648\u0645\u064a\u0646 \u062d\u0627\u0644\u064a\u064b\u0627 \u0628\u0627\u0644\u0631\u0636\u0627\u0639\u0629 \u0627\u0644\u0637\u0628\u064a\u0639\u064a\u0629\u061f <\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1395-0\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1395\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1395-1\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1395\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField1396\"><label for=\"vfb-field-1396\" class=\"vfb-control-label\">Miskraam?<\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u0633\u0628\u0642 \u0644\u0643\u0650 \u0623\u0646 \u062a\u0639\u0631\u0636\u062a\u0650 \u0644\u0633\u0642\u0637 (\u0648\u0644\u0627\u062f\u0629 \u0627\u0644\u062c\u0646\u064a\u0646 \u0645\u064a\u062a\u064b\u0627 \u0642\u0628\u0644 \u0645\u0648\u0639\u062f\u0647)\u061f <\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1396-0\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1396\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1396-1\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1396\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-radio\" id=\"vfbField1397\"><label for=\"vfb-field-1397\" class=\"vfb-control-label\">Eerder abortus gehad? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u0633\u0628\u0642 \u0644\u0643\u0650 \u0627\u0644\u0625\u062c\u0647\u0627\u0636\u061f <\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1397-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1397\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1397-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1397\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-textarea\" id=\"vfbField1398\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1398\" class=\"vfb-control-label\">Abortus in jaar en waar? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><textarea id=\"vfb-field-1398\" class=\"vfb-form-control\" placeholder=\"\u0625\u0630\u0627 \u0643\u0627\u0646 \u0627\u0644\u0623\u0645\u0631 \u0643\u0630\u0644\u0643 \u060c \u0641\u064a \u0623\u064a \u0633\u0646\u0629 \u0648\u0623\u064a\u0646\u061f\" required=\"required\" rows=\"5\" name=\"vfb-field-1398\" cols=\"50\"><\/textarea><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><\/div> <!-- .vfb-well --><div class=\"vfb-well vfb-col-12\" id=\"vfbField1399\"><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\"><\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField1399\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-radio\" id=\"vfbField1400\"><label for=\"vfb-field-1400\" class=\"vfb-control-label\">Bij gynaecoloog onder behandeling? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u0633\u0628\u0642 \u0623\u0646 \u062a\u0645\u062a \u0645\u0639\u0627\u0644\u062c\u062a\u0643\u0650 \u0645\u0646 \u0642\u0628\u0644 \u0637\u0628\u064a\u0628 \u0623\u0645\u0631\u0627\u0636 \u0646\u0633\u0627\u0621\u061f <\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1400-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1400\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1400-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1400\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-col-6 vfb-fieldType-textarea\" id=\"vfbField1401\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1401\" class=\"vfb-control-label\">Waarvoor? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0644\u0645\u0627\u0630\u0627\u061f <\/span><textarea id=\"vfb-field-1401\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" rows=\"4\" name=\"vfb-field-1401\" cols=\"50\"><\/textarea><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-radio\" id=\"vfbField1402\"><label for=\"vfb-field-1402\" class=\"vfb-control-label\">Behandeld voor geslachtsziekte?<\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u0645\u062a \u0645\u0639\u0627\u0644\u062c\u062a\u0643\u0650 \u0645\u0646 \u0645\u0631\u0636 \u0645\u0646\u0642\u0648\u0644 \u062c\u0646\u0633\u064a\u064b\u0627\u061f <\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1402-0\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1402\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1402-1\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1402\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField1403\"><label for=\"vfb-field-1403\" class=\"vfb-control-label\">Eileiderontsteking gehad?<\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u0633\u0628\u0642 \u0644\u0643\u0650 \u0623\u0646 \u062a\u0639\u0631\u0636\u062a\u0650 \u0644\u0627\u0644\u062a\u0647\u0627\u0628 \u0641\u064a \u0642\u0646\u0627\u0629 \u0641\u0627\u0644\u0648\u0628\u061f <\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1403-0\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1403\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1403-1\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1403\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-radio\" id=\"vfbField1404\"><label for=\"vfb-field-1404\" class=\"vfb-control-label\">Operatie ondergaan? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u0633\u0628\u0642 \u0644\u0643\u0650 \u0627\u0644\u062e\u0636\u0648\u0639 \u0644\u0639\u0645\u0644\u064a\u0629 \u062c\u0631\u0627\u062d\u064a\u0629\u061f <\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1404-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1404\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1404-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1404\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-col-6 vfb-fieldType-textarea\" id=\"vfbField1405\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1405\" class=\"vfb-control-label\">Waarom en wanneer? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0625\u0630\u0627 \u0643\u0627\u0646\u062a \u0627\u0644\u0625\u062c\u0627\u0628\u0629 \u201c\u0646\u0639\u0645\u201d\u060c \u0645\u062a\u0649 \u0648\u0644\u0645\u0627\u0630\u0627\u061f<\/span><textarea id=\"vfb-field-1405\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" rows=\"5\" name=\"vfb-field-1405\" cols=\"50\"><\/textarea><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField1406\"><label for=\"vfb-field-1406\" class=\"vfb-control-label\">Narcose gehad?<\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u0645\u062a \u0647\u0630\u0647 \u0627\u0644\u0639\u0645\u0644\u064a\u0629 \u0627\u0644\u062c\u0631\u0627\u062d\u064a\u0629 \u062a\u062d\u062a \u0627\u0644\u062a\u062e\u062f\u064a\u0631\u061f <\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1406-0\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1406\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1406-1\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1406\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField1407\"><label for=\"vfb-field-1407\" class=\"vfb-control-label\">Plaatselijke verdoving gehad?<\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u0633\u0628\u0642 \u0623\u0646 \u062e\u0636\u0639\u062a\u0650 \u0644\u062a\u062e\u062f\u064a\u0631 \u0645\u0648\u0636\u0639\u064a (\u0639\u0644\u0649 \u0633\u0628\u064a\u0644 \u0627\u0644\u0645\u062b\u0627\u0644 \u0639\u0646\u062f \u0637\u0628\u064a\u0628 \u0627\u0644\u0623\u0633\u0646\u0627\u0646)\u061f \r\n\r\n<\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1407-0\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1407\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1407-1\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1407\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-radio\" id=\"vfbField1408\"><label for=\"vfb-field-1408\" class=\"vfb-control-label\">Allergisch verdoving? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0625\u0630\u0627 \u0643\u0627\u0646 \u0627\u0644\u0623\u0645\u0631 \u0643\u0630\u0644\u0643: \u0647\u0644 \u0643\u0646\u062a \u062a\u0639\u0627\u0646\u064a \u0645\u0646 \u062d\u0633\u0627\u0633\u064a\u0629 (\u0634\u062f\u064a\u062f\u0629 \u0627\u0644\u062d\u0633\u0627\u0633\u064a\u0629) \u062a\u062c\u0627\u0647 \u0627\u0644\u0645\u062e\u062f\u0631\u061f\r\n<\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1408-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1408\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1408-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1408\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-col-6 vfb-fieldType-textarea\" id=\"vfbField1409\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1409\" class=\"vfb-control-label\">Allergische reacties <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0625\u0630\u0627 \u0643\u0627\u0646 \u0627\u0644\u0623\u0645\u0631 \u0643\u0630\u0644\u0643: \u0645\u0627 \u0647\u064a \u0631\u062f\u0648\u062f \u0627\u0644\u0641\u0639\u0644 \u0627\u0644\u062a\u062d\u0633\u0633\u064a\u0629 \u0627\u0644\u062a\u064a \u062a\u062d\u0635\u0644 \u0639\u0644\u064a\u0647\u0627\u061f<\/span><textarea id=\"vfb-field-1409\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" rows=\"5\" name=\"vfb-field-1409\" cols=\"50\"><\/textarea><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-radio\" id=\"vfbField1410\"><label for=\"vfb-field-1410\" class=\"vfb-control-label\">Onder behandeling geweest i.v.m. hart? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u0633\u0628\u0642 \u0644\u0643\u0650 \u0623\u0646 \u062e\u0636\u0639\u062a\u0650 \u0644\u0645\u064f\u0639\u0627\u0644\u062c\u0629 \u0644\u0644\u0642\u0644\u0628\u061f <\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1410-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1410\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1410-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1410\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-col-6 vfb-fieldType-textarea\" id=\"vfbField1411\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1411\" class=\"vfb-control-label\">Welk jaar en waarom? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0625\u0630\u0627 \u0643\u0627\u0646\u062a \u0627\u0644\u0625\u062c\u0627\u0628\u0629 \u201c\u0646\u0639\u0645\u201d\u060c \u0645\u062a\u0649 \u0648\u0644\u0645\u0627\u0630\u0627\u061f<\/span><textarea id=\"vfb-field-1411\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" rows=\"5\" name=\"vfb-field-1411\" cols=\"50\"><\/textarea><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><\/div> <!-- .vfb-well --><div class=\"vfb-well vfb-col-12\" id=\"vfbField1412\"><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\"><\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField1412\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-checkbox\" id=\"vfbField1413\"><label for=\"vfb-field-1413\" class=\"vfb-control-label\">Allergisch\/overgevoelig voor <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u0639\u0627\u0646\u064a\u0646 \u0645\u0646 \u062d\u0633\u0627\u0633\u064a\u0629 \u0623\u0648 \u0641\u0631\u0637 \u062d\u0633\u0627\u0633\u064a\u0629 \u062a\u062c\u0627\u0647: <\/span><div class=\"vfb-inline-group\"><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1413-0\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1413\" required=\"required\" type=\"checkbox\" name=\"vfb-field-1413[0]\" value=\"1\">\u0627\u0644\u064a\u0648\u062f (Jodium)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1413-1\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1413\" type=\"checkbox\" name=\"vfb-field-1413[1]\" value=\"1\">\u0627\u0644\u0636\u0645\u0627\u062f\u0627\u062a (Pleister)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1413-2\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1413\" type=\"checkbox\" name=\"vfb-field-1413[2]\" value=\"1\">\u0627\u0644\u0645\u0639\u0627\u062f\u0646 (\u0627\u0644\u0646\u064a\u0643\u0644 \/ \u0627\u0644\u0643\u0631\u0648\u0645) (Metaal\/ nikkel\/ chroom)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1413-3\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1413\" type=\"checkbox\" name=\"vfb-field-1413[3]\" value=\"1\">\u0627\u0644\u0645\u0637\u0627\u0637 \/ \u0627\u0644\u0644\u0627\u062a\u0643\u0633 \/ \u0627\u0644\u0643\u064a\u0648\u064a \/ \u0627\u0644\u062a\u064a\u0646 (Rubber \/ latex \/ kiwi\u2019s \/ vijgen)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1413-4\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1413\" type=\"checkbox\" name=\"vfb-field-1413[4]\" value=\"1\">\u0627\u0644\u0635\u0648\u064a\u0627 (Soya)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1413-5\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1413\" type=\"checkbox\" name=\"vfb-field-1413[5]\" value=\"1\">\u0623\u062f\u0648\u064a\u0629 (Geneesmiddelen)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1413-6\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1413\" type=\"checkbox\" name=\"vfb-field-1413[6]\" value=\"1\">\u0644\u0627 \u064a\u0646\u0637\u0628\u0642 (Niet van toepassing)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-textarea\" id=\"vfbField1414\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1414\" class=\"vfb-control-label\">Welke geneesmiddelen? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0623\u064a \u0627\u0644\u0623\u062f\u0648\u064a\u0629\u061f<\/span><textarea id=\"vfb-field-1414\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" rows=\"5\" name=\"vfb-field-1414\" cols=\"50\"><\/textarea><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-4 vfb-fieldType-radio\" id=\"vfbField1415\"><label for=\"vfb-field-1415\" class=\"vfb-control-label\">Overige allergie\u00ebn? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u064f\u0639\u0627\u0646\u064a\u0646 \u0645\u0646 \u0623\u064a \u062d\u0633\u0627\u0633\u064a\u0629 \u0623\u062e\u0631\u0649 \u0623\u0648 \u0645\u0646 \u0639\u062f\u0629 \u0623\u0646\u0648\u0627\u0639 \u062d\u0633\u0627\u0633\u064a\u0629\u061f <\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1415-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1415\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1415-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1415\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-col-4 vfb-fieldType-textarea\" id=\"vfbField1416\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1416\" class=\"vfb-control-label\">Welke allergie\u00ebn? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0625\u0630\u0627 \u0643\u0627\u0646\u062a \u0627\u0644\u0625\u062c\u0627\u0628\u0629 \u201c\u0646\u0639\u0645\u201d\u060c \u0641\u0645\u0627 \u0627\u0644\u0630\u064a \u062a\u0639\u0627\u0646\u064a\u0646 \u0645\u0646 \u0627\u0644\u062d\u0633\u0627\u0633\u064a\u0629 \u062a\u062c\u0627\u0647\u0647\u061f<\/span><textarea id=\"vfb-field-1416\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" rows=\"5\" name=\"vfb-field-1416\" cols=\"50\"><\/textarea><\/div><\/div><\/div><div class=\"vfb-col-4 vfb-fieldType-checkbox\" id=\"vfbField1417\"><label for=\"vfb-field-1417\" class=\"vfb-control-label\">Allergische reacties <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0645\u0627 \u0647\u064a \u0631\u062f\u0648\u062f \u0627\u0644\u0641\u0639\u0644 \u0627\u0644\u062a\u062d\u0633\u0633\u064a\u0629 \u0627\u0644\u062a\u064a \u062a\u062d\u0635\u0644 \u0639\u0644\u064a\u0647\u0627\u061f<\/span><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1417-0\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1417\" required=\"required\" type=\"checkbox\" name=\"vfb-field-1417[0]\" value=\"1\">\u0628\u0642\u0639 \u062d\u0645\u0631\u0627\u0621 (Rode vlekken)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1417-1\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1417\" type=\"checkbox\" name=\"vfb-field-1417[1]\" value=\"1\">\u062d\u0643\u0629 (Jeuk) <\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1417-2\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1417\" type=\"checkbox\" name=\"vfb-field-1417[2]\" value=\"1\">\u0645\u062e\u062a\u0644\u0641 (Anders)<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-radio\" id=\"vfbField1418\"><label for=\"vfb-field-1418\" class=\"vfb-control-label\">Eerste hulp ivm allergie? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u0633\u0628\u0642 \u0644\u0643 \u0623\u0646 \u062f\u062e\u0644\u062a \u063a\u0631\u0641\u0629 \u0627\u0644\u0637\u0648\u0627\u0631\u0626 \u0628\u0633\u0628\u0628 \u062d\u0633\u0627\u0633\u064a\u0629 \u0634\u062f\u064a\u062f\u0629\u061f\r\n<\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1418-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1418\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1418-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1418\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-textarea\" id=\"vfbField1419\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1419\" class=\"vfb-control-label\">Welk jaar en waarom? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0625\u0630\u0627 \u0643\u0627\u0646\u062a \u0627\u0644\u0625\u062c\u0627\u0628\u0629 \u0646\u0639\u0645 \u060c \u0641\u064a \u0623\u064a \u0633\u0646\u0629 \u0648\u0644\u0645\u0627\u0630\u0627\u061f<\/span><textarea id=\"vfb-field-1419\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" rows=\"5\" name=\"vfb-field-1419\" cols=\"50\"><\/textarea><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><\/div> <!-- .vfb-well --><div class=\"vfb-well vfb-col-12\" id=\"vfbField1420\"><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\"><\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField1420\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-radio\" id=\"vfbField1421\"><label for=\"vfb-field-1421\" class=\"vfb-control-label\">Geneesmiddelen\/medicijnen laatste 24 uur? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u0627\u0633\u062a\u062e\u062f\u0645\u062a\u0650 \u0623\u064a \u0623\u062f\u0648\u064a\u0629\/\u0639\u0644\u0627\u062c\u0627\u062a\u060c \u0628\u0645\u0627 \u0641\u064a \u0630\u0644\u0643 \u0627\u0644\u0646\u0641\u062e\u0627\u062a \u0623\u0648 \u0646\u0628\u062a\u0629 \u0627\u0644\u0639\u0631\u0646 \u0627\u0644\u0645\u062b\u0642\u0648\u0628\u060c \u062e\u0644\u0627\u0644 \u0627\u0644\u0640 24 \u0633\u0627\u0639\u0629 \u0627\u0644\u0645\u0627\u0636\u064a\u0629\u061f<\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1421-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1421\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1421-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1421\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-col-6 vfb-fieldType-textarea\" id=\"vfbField1422\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1422\" class=\"vfb-control-label\">Welke medicijnen? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0625\u0630\u0627 \u0643\u0627\u0646\u062a \u0627\u0644\u0625\u062c\u0627\u0628\u0629 \u201c\u0646\u0639\u0645\u201d\u060c \u0641\u0645\u0627 \u0647\u064a \u0647\u0630\u0647 \u0627\u0644\u0623\u062f\u0648\u064a\u0629\u061f<\/span><textarea id=\"vfb-field-1422\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" rows=\"5\" name=\"vfb-field-1422\" cols=\"50\"><\/textarea><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-radio\" id=\"vfbField1423\"><label for=\"vfb-field-1423\" class=\"vfb-control-label\">Drugs laatste 24 uur? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u0639\u0627\u0637\u064a\u062a\u0650 \u0645\u064f\u062e\u062f\u0631\u0627\u062a \u062e\u0644\u0627\u0644 \u0627\u0644\u0640 24 \u0633\u0627\u0639\u0629 \u0627\u0644\u0645\u0627\u0636\u064a\u0629\u061f<\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1423-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1423\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1423-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1423\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-col-6 vfb-fieldType-textarea\" id=\"vfbField1424\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1424\" class=\"vfb-control-label\">Welke drugs? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0625\u0630\u0627 \u0643\u0627\u0646\u062a \u0627\u0644\u0625\u062c\u0627\u0628\u0629 \u201c\u0646\u0639\u0645\u201d\u060c \u0641\u0645\u0627 \u0647\u064a \u0647\u0630\u0647 \u0627\u0644\u0645\u062e\u062f\u0631\u0627\u062a\u061f<\/span><textarea id=\"vfb-field-1424\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" rows=\"5\" name=\"vfb-field-1424\" cols=\"50\"><\/textarea><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-radio\" id=\"vfbField1425\"><label for=\"vfb-field-1425\" class=\"vfb-control-label\">Rookt u? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u062f\u062e\u0646\u064a\u0646\u061f <\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1425-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1425\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1425-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1425\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-col-6 vfb-fieldType-text\" id=\"vfbField1426\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1426\" class=\"vfb-control-label\">Aantal per dag?<\/label><div><input id=\"vfb-field-1426\" class=\"vfb-form-control\" placeholder=\"\u0625\u0630\u0627 \u0643\u0627\u0646\u062a \u0627\u0644\u0625\u062c\u0627\u0628\u0629 &ldquo;\u0646\u0639\u0645&rdquo;\u060c \u0641\u0643\u0645 \u0639\u062f\u062f \u0627\u0644\u0633\u062c\u0627\u0626\u0631 \u0627\u0644\u062a\u064a \u062a\u062f\u062e\u0646\u064a\u0646\u0647\u0627 \u064a\u0648\u0645\u064a\u064b\u0627\u061f\" type=\"text\" name=\"vfb-field-1426\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-radio\" id=\"vfbField1427\"><label for=\"vfb-field-1427\" class=\"vfb-control-label\">Drink je? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u0634\u0631\u0628\u064a\u0646 \u0645\u0634\u0631\u0648\u0628\u0627\u062a \u0643\u062d\u0648\u0644\u064a\u0629\u061f <\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1427-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1427\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1427-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1427\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-col-6 vfb-fieldType-text\" id=\"vfbField1428\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1428\" class=\"vfb-control-label\">Aantal glazen per week?<\/label><div><input id=\"vfb-field-1428\" class=\"vfb-form-control\" placeholder=\"\u0625\u0630\u0627 \u0643\u0627\u0646\u062a \u0627\u0644\u0625\u062c\u0627\u0628\u0629 &quot;\u0646\u0639\u0645&quot;\u060c \u0641\u0643\u0645 \u0643\u0623\u0633\u064b\u0627 \u062a\u0634\u0631\u0628\u064a\u0646 \u0641\u064a \u0627\u0644\u0623\u0633\u0628\u0648\u0639 \" type=\"text\" name=\"vfb-field-1428\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-checkbox\" id=\"vfbField1429\"><label for=\"vfb-field-1429\" class=\"vfb-control-label\">Slachtoffer huiselijk geweld?<\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u0633\u0628\u0642 \u0623\u0646 \u0648\u0642\u0639\u062a\u0650 \u0636\u062d\u064a\u0629 \u0644\u0639\u0646\u0641 \u0645\u0646\u0632\u0644\u064a\u061f <\/span><div class=\"vfb-inline-group\"><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1429-0\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1429\" type=\"checkbox\" name=\"vfb-field-1429[0]\" value=\"1\">(Nee) \u0644\u0627<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1429-1\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1429\" type=\"checkbox\" name=\"vfb-field-1429[1]\" value=\"1\">(Ja, fysiek)  \u0646\u0639\u0645\u060c \u0639\u0646\u0641 \u062c\u0633\u062f\u064a<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1429-2\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1429\" type=\"checkbox\" name=\"vfb-field-1429[2]\" value=\"1\">(Ja, seksueel) \u0646\u0639\u0645\u060c \u0627\u0639\u062a\u062f\u0627\u0621 \u062c\u0646\u0633\u064a <\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1429-3\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1429\" type=\"checkbox\" name=\"vfb-field-1429[3]\" value=\"1\">(Ja, geestelijk) \u0646\u0639\u0645\u060c \u0625\u064a\u0630\u0627\u0621 \u0646\u0641\u0633\u064a<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField1430\"><label for=\"vfb-field-1430\" class=\"vfb-control-label\">Slachtoffer negatieve seksuele ervaringen?<\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u0633\u0628\u0642 \u0623\u0646 \u0648\u0642\u0639\u062a\u0650 \u0636\u062d\u064a\u0629 \u0644\u062a\u062c\u0631\u0628\u0629 \u0623\u0648 \u062a\u062c\u0627\u0631\u0628 \u062c\u0646\u0633\u064a\u0629 \u0633\u0644\u0628\u064a\u0629 \u062e\u0627\u0631\u062c \u0627\u0644\u0645\u0646\u0632\u0644\u061f <\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1430-0\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1430\" value=\"(ja) \u0646\u0639\u0645\">(ja) \u0646\u0639\u0645<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1430-1\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1430\" value=\"(nee) \u0644\u0627\">(nee) \u0644\u0627<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><\/div> <!-- .vfb-well --><div class=\"vfb-well vfb-col-12\" id=\"vfbField1431\"><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\"><\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField1431\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-checkbox\" id=\"vfbField1432\"><label for=\"vfb-field-1432\" class=\"vfb-control-label\">Ziektes <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u0639\u0627\u0646\u064a\u0646 \u062d\u0627\u0644\u064a\u064b\u0627 \u0645\u0646 \u0623\u064a \u0645\u0646 \u0627\u0644\u0623\u0645\u0631\u0627\u0636 \u0627\u0644\u062a\u0627\u0644\u064a\u0629\u061f \u0623\u0648 \u0639\u0627\u0646\u064a\u062a\u0650 \u0645\u0646\u0647\u0627 \u0641\u064a \u0627\u0644\u0633\u0627\u0628\u0642\u061f <\/span><div class=\"vfb-row\"><div class=\"vfb-col-4\"><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1432-0\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1432\" required=\"required\" type=\"checkbox\" name=\"vfb-field-1432[0]\" value=\"1\">\u0627\u0631\u062a\u0641\u0627\u0639 \u0636\u063a\u0637 \u0627\u0644\u062f\u0645 (Hoge bloeddruk)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1432-1\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1432\" type=\"checkbox\" name=\"vfb-field-1432[1]\" value=\"1\">\u0627\u0644\u062a\u0639\u0631\u0636 \u0644\u062c\u0644\u0637\u0629 \u062f\u0645\u0648\u064a\u0629 (\u0641\u064a \u0627\u0644\u0633\u0627\u0628\u0642) (Trombose (in verleden)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1432-2\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1432\" type=\"checkbox\" name=\"vfb-field-1432[2]\" value=\"1\">\u0641\u0642\u0631 \u0627\u0644\u062f\u0645 (\u062e\u0644\u0627\u0644 \u0627\u0644\u0623\u0634\u0647\u0631 \u0627\u0644\u0633\u062a\u0629 \u0627\u0644\u0645\u0627\u0636\u064a\u0629) (Bloedarmoede (in laatste half jaar)<\/label><\/div><\/div><div class=\"vfb-col-4\"><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1432-3\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1432\" type=\"checkbox\" name=\"vfb-field-1432[3]\" value=\"1\">\u0627\u0644\u062a\u0647\u0627\u0628 \u0627\u0644\u0645\u062b\u0627\u0646\u0629 (\u062e\u0644\u0627\u0644 \u0627\u0644\u0623\u0634\u0647\u0631 \u0627\u0644\u0633\u062a\u0629 \u0627\u0644\u0645\u0627\u0636\u064a\u0629) Blaasontsteking (in laatste half jaar)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1432-4\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1432\" type=\"checkbox\" name=\"vfb-field-1432[4]\" value=\"1\">\u0627\u0644\u062a\u0639\u0631\u0636 \u0644\u0644\u0625\u063a\u0645\u0627\u0621\/\u0641\u0631\u0637 \u0627\u0644\u062a\u0646\u0641\u0633(Last van flauwvallen\/hyperventilatie)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1432-5\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1432\" type=\"checkbox\" name=\"vfb-field-1432[5]\" value=\"1\">\u0635\u062f\u0627\u0639 \u0646\u0635\u0641\u064a \u0645\u0639 \u0623\u0648\u0631\u0629 (Migraine met aura)<\/label><\/div><\/div><div class=\"vfb-col-4\"><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1432-6\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1432\" type=\"checkbox\" name=\"vfb-field-1432[6]\" value=\"1\">\u0641\u0642\u0631 \u0627\u0644\u062f\u0645 \u0627\u0644\u0645\u0646\u062c\u0644\u064a \/ \u0627\u0644\u062b\u0644\u0627\u0633\u064a\u0645\u064a\u0627 (Sikkelcelanemie \/ thalassemie)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1432-7\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1432\" type=\"checkbox\" name=\"vfb-field-1432[7]\" value=\"1\">\u0644\u0627 \u064a\u0646\u0637\u0628\u0642 (Niet van toepassing)<\/label><\/div><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-textarea\" id=\"vfbField1433\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1433\" class=\"vfb-control-label\">Wanneer voor het laatst klachten? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0625\u0630\u0627 \u0643\u0627\u0646\u062a \u0627\u0644\u0625\u062c\u0627\u0628\u0629 \u201c\u0646\u0639\u0645\u201d\u060c \u0641\u0641\u064a \u0623\u064a \u0639\u0627\u0645 \u0639\u0627\u0646\u064a\u062a\u0650 \u0645\u0646 \u0627\u0644\u0634\u0643\u0627\u0648\u0649 \u0622\u062e\u0631 \u0645\u0631\u0629\u061f<\/span><textarea id=\"vfb-field-1433\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" rows=\"5\" name=\"vfb-field-1433\" cols=\"50\"><\/textarea><\/div><\/div><\/div><div class=\"vfb-col-6 vfb-fieldType-radio\" id=\"vfbField1434\"><label for=\"vfb-field-1434\" class=\"vfb-control-label\">Onder behandeling arts?<\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u064f\u0639\u0627\u0644\u062c\u064a\u0646 \u0645\u0646 \u0630\u0644\u0643 \u0644\u062f\u0649 \u0637\u0628\u064a\u0628\u061f<\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1434-0\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1434\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1434-1\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1434\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField1435\"><label for=\"vfb-field-1435\" class=\"vfb-control-label\">Bloedstollingstoornissen? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u0639\u0627\u0646\u064a\u0646 \u0645\u0646 \u0627\u0636\u0637\u0631\u0627\u0628\u0627\u062a \u062a\u062e\u062b\u0631 \u0627\u0644\u062f\u0645\u061f<\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1435-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1435\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1435-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1435\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-textarea\" id=\"vfbField1436\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1436\" class=\"vfb-control-label\">Wanneer voor het laatst klachten? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0625\u0630\u0627 \u0643\u0627\u0646\u062a \u0627\u0644\u0625\u062c\u0627\u0628\u0629 \u201c\u0646\u0639\u0645\u201d\u060c \u0641\u0641\u064a \u0623\u064a \u0639\u0627\u0645 \u0639\u0627\u0646\u064a\u062a\u0650 \u0645\u0646 \u0627\u0644\u0634\u0643\u0627\u0648\u0649 \u0622\u062e\u0631 \u0645\u0631\u0629\u061f<\/span><textarea id=\"vfb-field-1436\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" rows=\"5\" name=\"vfb-field-1436\" cols=\"50\"><\/textarea><\/div><\/div><\/div><div class=\"vfb-col-6 vfb-fieldType-radio\" id=\"vfbField1437\"><label for=\"vfb-field-1437\" class=\"vfb-control-label\">Onder behandeling arts?<\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u064f\u0639\u0627\u0644\u062c\u064a\u0646 \u0645\u0646 \u0630\u0644\u0643 \u0644\u062f\u0649 \u0637\u0628\u064a\u0628\u061f<\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1437-0\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1437\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1437-1\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1437\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField1438\"><label for=\"vfb-field-1438\" class=\"vfb-control-label\">Nierziekte? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u0639\u0627\u0646\u064a\u0646 \u0645\u0646 \u0645\u0631\u0636 \u0643\u0644\u0648\u064a\u061f <\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1438-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1438\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1438-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1438\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-textarea\" id=\"vfbField1439\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1439\" class=\"vfb-control-label\">Wanneer voor het laatst klachten? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0625\u0630\u0627 \u0643\u0627\u0646\u062a \u0627\u0644\u0625\u062c\u0627\u0628\u0629 \u201c\u0646\u0639\u0645\u201d\u060c \u0641\u0641\u064a \u0623\u064a \u0639\u0627\u0645 \u0639\u0627\u0646\u064a\u062a\u0650 \u0645\u0646 \u0627\u0644\u0634\u0643\u0627\u0648\u0649 \u0622\u062e\u0631 \u0645\u0631\u0629\u061f<\/span><textarea id=\"vfb-field-1439\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" rows=\"5\" name=\"vfb-field-1439\" cols=\"50\"><\/textarea><\/div><\/div><\/div><div class=\"vfb-col-6 vfb-fieldType-radio\" id=\"vfbField1440\"><label for=\"vfb-field-1440\" class=\"vfb-control-label\">Onder behandeling arts?<\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u064f\u0639\u0627\u0644\u062c\u064a\u0646 \u0645\u0646 \u0630\u0644\u0643 \u0644\u062f\u0649 \u0637\u0628\u064a\u0628\u061f<\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1440-0\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1440\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1440-1\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1440\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField1441\"><label for=\"vfb-field-1441\" class=\"vfb-control-label\">Ziekten van de schildklier? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u0639\u0627\u0646\u064a\u0646 \u0645\u0646 \u0645\u0634\u0643\u0644\u0627\u062a \u0641\u064a \u0627\u0644\u063a\u062f\u0629 \u0627\u0644\u062f\u0631\u0642\u064a\u0629\u061f <\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1441-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1441\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1441-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1441\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-textarea\" id=\"vfbField1442\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1442\" class=\"vfb-control-label\">Wanneer voor het laatst klachten? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0625\u0630\u0627 \u0643\u0627\u0646\u062a \u0627\u0644\u0625\u062c\u0627\u0628\u0629 \u201c\u0646\u0639\u0645\u201d\u060c \u0641\u0641\u064a \u0623\u064a \u0639\u0627\u0645 \u0639\u0627\u0646\u064a\u062a\u0650 \u0645\u0646 \u0627\u0644\u0634\u0643\u0627\u0648\u0649 \u0622\u062e\u0631 \u0645\u0631\u0629\u061f<\/span><textarea id=\"vfb-field-1442\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" rows=\"5\" name=\"vfb-field-1442\" cols=\"50\"><\/textarea><\/div><\/div><\/div><div class=\"vfb-col-6 vfb-fieldType-radio\" id=\"vfbField1443\"><label for=\"vfb-field-1443\" class=\"vfb-control-label\">Onder behandeling arts?<\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u064f\u0639\u0627\u0644\u062c\u064a\u0646 \u0645\u0646 \u0630\u0644\u0643 \u0644\u062f\u0649 \u0637\u0628\u064a\u0628\u061f<\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1443-0\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1443\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1443-1\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1443\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField1444\"><label for=\"vfb-field-1444\" class=\"vfb-control-label\">Diabetes? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u0639\u0627\u0646\u064a\u0646 \u0645\u0646 \u0645\u0631\u0636 \u0627\u0644\u0633\u0643\u0631\u064a (\u062f\u0627\u0621 \u0627\u0644\u0633\u0643\u0631\u064a)\u061f <\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1444-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1444\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1444-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1444\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-textarea\" id=\"vfbField1445\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1445\" class=\"vfb-control-label\">Wanneer voor het laatst klachten? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0625\u0630\u0627 \u0643\u0627\u0646\u062a \u0627\u0644\u0625\u062c\u0627\u0628\u0629 \u201c\u0646\u0639\u0645\u201d\u060c \u0641\u0641\u064a \u0623\u064a \u0639\u0627\u0645 \u0639\u0627\u0646\u064a\u062a\u0650 \u0645\u0646 \u0627\u0644\u0634\u0643\u0627\u0648\u0649 \u0622\u062e\u0631 \u0645\u0631\u0629\u061f<\/span><textarea id=\"vfb-field-1445\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" rows=\"5\" name=\"vfb-field-1445\" cols=\"50\"><\/textarea><\/div><\/div><\/div><div class=\"vfb-col-6 vfb-fieldType-radio\" id=\"vfbField1446\"><label for=\"vfb-field-1446\" class=\"vfb-control-label\">Onder behandeling arts?<\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u064f\u0639\u0627\u0644\u062c\u064a\u0646 \u0645\u0646 \u0630\u0644\u0643 \u0644\u062f\u0649 \u0637\u0628\u064a\u0628\u061f<\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1446-0\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1446\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1446-1\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1446\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField1447\"><label for=\"vfb-field-1447\" class=\"vfb-control-label\">Leverziekte? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u0639\u0627\u0646\u064a\u0646 \u0645\u0646 \u0645\u0631\u0636 \u0641\u064a \u0627\u0644\u0643\u0628\u062f (\u0627\u0644\u062a\u0647\u0627\u0628 \u0627\u0644\u0643\u0628\u062f \u0627\u0644\u0648\u0628\u0627\u0626\u064a \/ \u0627\u0644\u064a\u0631\u0642\u0627\u0646)\u061f <\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1447-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1447\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1447-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1447\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-textarea\" id=\"vfbField1448\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1448\" class=\"vfb-control-label\">Wanneer voor het laatst klachten? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0625\u0630\u0627 \u0643\u0627\u0646\u062a \u0627\u0644\u0625\u062c\u0627\u0628\u0629 \u201c\u0646\u0639\u0645\u201d\u060c \u0641\u0641\u064a \u0623\u064a \u0639\u0627\u0645 \u0639\u0627\u0646\u064a\u062a\u0650 \u0645\u0646 \u0627\u0644\u0634\u0643\u0627\u0648\u0649 \u0622\u062e\u0631 \u0645\u0631\u0629\u061f<\/span><textarea id=\"vfb-field-1448\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" rows=\"5\" name=\"vfb-field-1448\" cols=\"50\"><\/textarea><\/div><\/div><\/div><div class=\"vfb-col-6 vfb-fieldType-radio\" id=\"vfbField1449\"><label for=\"vfb-field-1449\" class=\"vfb-control-label\">Onder behandeling arts?<\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u064f\u0639\u0627\u0644\u062c\u064a\u0646 \u0645\u0646 \u0630\u0644\u0643 \u0644\u062f\u0649 \u0637\u0628\u064a\u0628\u061f<\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1449-0\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1449\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1449-1\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1449\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField1450\"><label for=\"vfb-field-1450\" class=\"vfb-control-label\">Astma of chronische bronchitis? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u0639\u0627\u0646\u064a\u0646 \u0645\u0646 \u0627\u0644\u0631\u0628\u0648 \u0623\u0648 \u0627\u0644\u062a\u0647\u0627\u0628 \u0627\u0644\u0634\u0639\u0628 \u0627\u0644\u0647\u0648\u0627\u0626\u064a\u0629 \u0627\u0644\u0645\u0632\u0645\u0646\u061f<\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1450-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1450\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1450-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1450\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-textarea\" id=\"vfbField1451\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1451\" class=\"vfb-control-label\">Wanneer voor het laatst klachten? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0625\u0630\u0627 \u0643\u0627\u0646\u062a \u0627\u0644\u0625\u062c\u0627\u0628\u0629 \u201c\u0646\u0639\u0645\u201d\u060c \u0641\u0641\u064a \u0623\u064a \u0639\u0627\u0645 \u0639\u0627\u0646\u064a\u062a\u0650 \u0645\u0646 \u0627\u0644\u0634\u0643\u0627\u0648\u0649 \u0622\u062e\u0631 \u0645\u0631\u0629\u061f<\/span><textarea id=\"vfb-field-1451\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" rows=\"5\" name=\"vfb-field-1451\" cols=\"50\"><\/textarea><\/div><\/div><\/div><div class=\"vfb-col-6 vfb-fieldType-radio\" id=\"vfbField1452\"><label for=\"vfb-field-1452\" class=\"vfb-control-label\">Onder behandeling arts?<\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u064f\u0639\u0627\u0644\u062c\u064a\u0646 \u0645\u0646 \u0630\u0644\u0643 \u0644\u062f\u0649 \u0637\u0628\u064a\u0628\u061f<\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1452-0\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1452\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1452-1\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1452\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField1453\"><label for=\"vfb-field-1453\" class=\"vfb-control-label\">Psychische\/psychiatrische aandoening? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u0639\u0627\u0646\u064a\u0646 \u0645\u0646 \u0645\u0631\u0636 \u0646\u0641\u0633\u064a \u0623\u0648 \u0639\u0642\u0644\u064a\u061f <\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1453-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1453\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1453-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1453\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-textarea\" id=\"vfbField1454\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1454\" class=\"vfb-control-label\">Wanneer voor het laatst klachten? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0625\u0630\u0627 \u0643\u0627\u0646\u062a \u0627\u0644\u0625\u062c\u0627\u0628\u0629 \u201c\u0646\u0639\u0645\u201d\u060c \u0641\u0641\u064a \u0623\u064a \u0639\u0627\u0645 \u0639\u0627\u0646\u064a\u062a\u0650 \u0645\u0646 \u0627\u0644\u0634\u0643\u0627\u0648\u0649 \u0622\u062e\u0631 \u0645\u0631\u0629\u061f<\/span><textarea id=\"vfb-field-1454\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" rows=\"5\" name=\"vfb-field-1454\" cols=\"50\"><\/textarea><\/div><\/div><\/div><div class=\"vfb-col-6 vfb-fieldType-radio\" id=\"vfbField1455\"><label for=\"vfb-field-1455\" class=\"vfb-control-label\">Onder behandeling arts?<\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u064f\u0639\u0627\u0644\u062c\u064a\u0646 \u0645\u0646 \u0630\u0644\u0643 \u0644\u062f\u0649 \u0637\u0628\u064a\u0628\u061f<\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1455-0\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1455\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1455-1\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1455\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField1456\"><label for=\"vfb-field-1456\" class=\"vfb-control-label\">Epilepsie (vallende ziekte)? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u0639\u0627\u0646\u064a\u0646 \u0645\u0646 \u0627\u0644\u0635\u0631\u0639 (\u0645\u0631\u0636 \u0627\u0644\u0633\u0642\u0648\u0637 \u0648\u0627\u0644\u062a\u0634\u0646\u062c)\u061f <\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1456-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1456\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1456-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1456\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-textarea\" id=\"vfbField1457\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1457\" class=\"vfb-control-label\">Wanneer voor het laatst klachten? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">\u0625\u0630\u0627 \u0643\u0627\u0646\u062a \u0627\u0644\u0625\u062c\u0627\u0628\u0629 \u201c\u0646\u0639\u0645\u201d\u060c \u0641\u0641\u064a \u0623\u064a \u0639\u0627\u0645 \u0639\u0627\u0646\u064a\u062a\u0650 \u0645\u0646 \u0627\u0644\u0634\u0643\u0627\u0648\u0649 \u0622\u062e\u0631 \u0645\u0631\u0629\u061f<\/span><textarea id=\"vfb-field-1457\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" rows=\"5\" name=\"vfb-field-1457\" cols=\"50\"><\/textarea><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-radio\" id=\"vfbField1458\"><label for=\"vfb-field-1458\" class=\"vfb-control-label\">Onder behandeling arts?<\/label><div><span class=\"vfb-help-block\">\u0647\u0644 \u062a\u064f\u0639\u0627\u0644\u062c\u064a\u0646 \u0645\u0646 \u0630\u0644\u0643 \u0644\u062f\u0649 \u0637\u0628\u064a\u0628\u061f<\/span><div class=\"vfb-inline-group\"><div class=\"vfb-radio\"><label><input id=\"vfb-field-1458-0\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1458\" value=\"\u0646\u0639\u0645 (ja)\">\u0646\u0639\u0645 (ja)<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1458-1\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-1458\" value=\"\u0644\u0627 (nee)\">\u0644\u0627 (nee)<\/label><\/div><\/div><\/div><\/div><\/div> <!-- .vfb-well --><div class=\"vfb-well vfb-col-12\" id=\"vfbField1459\"><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\"><\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField1459\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-captcha\" id=\"vfbField1460\"><div class=\"vfb-form-group\"><div><div class=\"g-recaptcha-v3\" data-sitekey=\"6LdaVKwpAAAAAJJS2gHjtFFboOB5PN9_fuyUw9FK\"><\/div><input type=\"hidden\" name=\"_vfb_recaptcha_enabled\" value=\"1\" id=\"\"><input type=\"hidden\" id=\"g-recaptcha-response\" name=\"g-recaptcha-response\"><div class=\"vfb-has-error\" id=\"vfb-recaptcha-error\"><span class=\"vfb-help-block\">reCAPTCHA is required.<\/span><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-submit\" id=\"vfbField1461\"><button id=\"vfb-field-1461\" class=\" btn btn-primary\" placeholder=\"\" type=\"submit\" name=\"_vfb-submit\">Verzenden<\/button><\/div><div class=\"vfb-clearfix\"><\/div><\/div> <!-- .vfb-well --><\/form>    <\/div>\n<\/div>\n<!-- \/module plain text -->        <\/div>\n                        <\/div>\n        <\/div>\n        <\/div>\n<!--\/themify_builder_content-->","protected":false},"excerpt":{"rendered":"<p>\u0634\u0643\u0644 \u0627\u0644\u062a\u0627\u0631\u064a\u062e \u0627\u0645\u0644\u0623 \u0646\u0645\u0648\u0630\u062c \u0627\u0644\u0623\u0633\u0626\u0644\u0629 \u0639\u0628\u0631 \u0627\u0644\u0625\u0646\u062a\u0631\u0646\u062a \u0623\u062f\u0646\u0627\u0647. \u00a0 \u062a\u064f\u0639\u0627\u0644\u062c \u0639\u064a\u0627\u062f\u0629 \u0627\u0644\u0625\u062c\u0647\u0627\u0636 Stimezo Zwolle \u0628\u064a\u0627\u0646\u0627\u062a\u0643\u0650 \u0628\u0639\u0646\u0627\u064a\u0629. \u00a0<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"inline_featured_image":false,"footnotes":""},"class_list":["post-4609","page","type-page","status-publish","hentry","has-post-title","has-post-date","has-post-category","has-post-tag","has-post-comment","has-post-author",""],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.8 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Anamneseformulier - Abortuskliniek Stimezo - Tel. 038-4217000<\/title>\n<meta name=\"description\" content=\"Download het Anamneseformulier (gezondheidsvragenlijst), vul deze in en stuur deze naar vragen@stimezo-zwolle.nl\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" 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