{"id":18128,"date":"2024-11-02T15:09:24","date_gmt":"2024-11-02T07:09:24","guid":{"rendered":"https:\/\/cosmointel.com\/?page_id=18128"},"modified":"2026-03-12T20:25:36","modified_gmt":"2026-03-12T12:25:36","slug":"treatment-report","status":"publish","type":"page","link":"https:\/\/cosmointel.com\/fa\/treatment-report\/","title":{"rendered":"\u06af\u0632\u0627\u0631\u0634 \u062f\u0631\u0645\u0627\u0646"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"18128\" class=\"elementor elementor-18128\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-017c87e e-con-full e-flex e-con e-parent\" data-id=\"017c87e\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-d8e6d5f elementor-widget elementor-widget-text-editor\" data-id=\"d8e6d5f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p style=\"text-align: justify;\"><span style=\"color: #000000;\"><strong><span style=\"font-size: 16px;\">Since our main goal is to help patients and those who are affected by addiction to quit, we encourage you to submit your treatment report and\/or your rehabilitation experience, using Connection to Cosmic Internet.<\/span><\/strong><\/span><\/p><p style=\"text-align: justify;\"><span style=\"color: #000000;\"><strong><span style=\"font-size: 16px;\">Hence, if you have requested for the Connection before and improved successfully, you can submit your report and medical documents now. You can briefly tell us about your disease\/addiction type, your experience, improvement, and any changes in your heath condition while using Connection. Feel free to choose a nickname if you do not like to use your really name. Your personal information and data will be kept confidential.<\/span><\/strong><\/span><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-9c9aabf elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"9c9aabf\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-8427856\" data-id=\"8427856\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-1587ca1 elementor-widget elementor-widget-tp-wp-forms\" data-id=\"1587ca1\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"tp-wp-forms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"pt_plus_wpforms\" \" ><style id=\"wpforms-css-vars-18076\">\n\t\t\t\t#wpforms-18076 {\n\t\t\t\t--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-18076\"><form id=\"wpforms-form-18076\" class=\"wpforms-validate wpforms-form\" data-formid=\"18076\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/treatment-report\/?wpforms_form_id=18076\" data-token=\"332dd33ea8736c5b216158448b989c26\" data-token-time=\"1775281582\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-18076-field_39-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"39\"><fieldset><legend class=\"wpforms-field-label\">Choose One <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-18076-field_39\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-18076-field_39_1\" name=\"wpforms[fields][39]\" value=\"Treatment Report\" aria-errormessage=\"wpforms-18076-field_39_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_39_1\">Treatment Report<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-18076-field_39_2\" name=\"wpforms[fields][39]\" value=\"Rehabitation Report\" aria-errormessage=\"wpforms-18076-field_39_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_39_2\">Rehabitation Report<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-18076-field_33-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_33\">Full Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-18076-field_33\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][33]\" aria-errormessage=\"wpforms-18076-field_33-error\" required><\/div><div id=\"wpforms-18076-field_45-container\" class=\"wpforms-field wpforms-field-number wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"45\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_45\">Age <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-18076-field_45\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][45]\" step=\"any\" aria-errormessage=\"wpforms-18076-field_45-error\" required><\/div><div id=\"wpforms-18076-field_46-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"46\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Gender <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-18076-field_46\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_46_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][46][]\" value=\"Male\" aria-errormessage=\"wpforms-18076-field_46_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_46_1\">Male<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_46_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][46][]\" value=\"Female\" aria-errormessage=\"wpforms-18076-field_46_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_46_2\">Female<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_46_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][46][]\" value=\"Other\" aria-errormessage=\"wpforms-18076-field_46_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_46_3\">Other<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-18076-field_35-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"35\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_35\">Country <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-18076-field_35\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][35]\" aria-errormessage=\"wpforms-18076-field_35-error\" required><\/div><div id=\"wpforms-18076-field_36-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"36\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_36\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-18076-field_36\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][36]\" spellcheck=\"false\" aria-errormessage=\"wpforms-18076-field_36-error\" required><\/div><div id=\"wpforms-18076-field_73-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"73\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tPhysical Symptoms Prior to Starting Faradarmani Treatment:\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-18076-field_56-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"56\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_56\">1.\tDescription of Symptoms: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-18076-field_56\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][56]\" aria-errormessage=\"wpforms-18076-field_56-error\" required><\/textarea><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-18076-field_68-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"68\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_68\">2.\tOnset of Symptoms: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-18076-field_68\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][68]\" aria-errormessage=\"wpforms-18076-field_68-error\" required><\/textarea><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-18076-field_69-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"69\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_69\">3.\tSeverity of Symptoms: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-18076-field_69\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][69]\" aria-errormessage=\"wpforms-18076-field_69-error\" required><\/textarea><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-18076-field_70-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"70\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_70\">4.\tFactors That Alleviate or Exacerbate Symptoms (Prior to Faradarmani): <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-18076-field_70\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][70]\" aria-errormessage=\"wpforms-18076-field_70-error\" required><\/textarea><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-18076-field_71-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"71\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_71\">5.\tIs this the first time you have experienced these symptoms? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-18076-field_71\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][71]\" aria-errormessage=\"wpforms-18076-field_71-error\" required><\/textarea><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-18076-field_72-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"72\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_72\">6.\tPhysician(s)\u2019 Diagnosis:  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-18076-field_72\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][72]\" aria-errormessage=\"wpforms-18076-field_72-error\" aria-describedby=\"wpforms-18076-field_72-description\" required><\/textarea><div id=\"wpforms-18076-field_72-description\" class=\"wpforms-field-description\">If you've undergone a specific medical pathway for diagnosis or consulted multiple doctors with differing diagnoses, please mention all of them.<\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-18076-field_75-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"75\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">7.\tSymptoms Experienced at Diagnosis (please select):<\/legend><ul id=\"wpforms-18076-field_75\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_75_1\" name=\"wpforms[fields][75][]\" value=\"Heart Palpitations\" aria-errormessage=\"wpforms-18076-field_75_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_75_1\">Heart Palpitations<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_75_2\" name=\"wpforms[fields][75][]\" value=\"Chest Pain\" aria-errormessage=\"wpforms-18076-field_75_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_75_2\">Chest Pain<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_75_3\" name=\"wpforms[fields][75][]\" value=\"Shortness of Breath\" aria-errormessage=\"wpforms-18076-field_75_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_75_3\">Shortness of Breath<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_75_4\" name=\"wpforms[fields][75][]\" value=\"Fever\" aria-errormessage=\"wpforms-18076-field_75_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_75_4\">Fever<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_75_5\" name=\"wpforms[fields][75][]\" value=\"Night Sweats\" aria-errormessage=\"wpforms-18076-field_75_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_75_5\">Night Sweats<\/label><\/li><li class=\"choice-28 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_75_28\" name=\"wpforms[fields][75][]\" value=\"Urinary Changes\" aria-errormessage=\"wpforms-18076-field_75_28-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_75_28\">Urinary Changes<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_75_7\" name=\"wpforms[fields][75][]\" value=\"Sleep Disturbance\" aria-errormessage=\"wpforms-18076-field_75_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_75_7\">Sleep Disturbance<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_75_8\" name=\"wpforms[fields][75][]\" value=\"Cold or Heat Intolerance\" aria-errormessage=\"wpforms-18076-field_75_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_75_8\">Cold or Heat Intolerance<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_75_9\" name=\"wpforms[fields][75][]\" value=\"Hand Tremors\" aria-errormessage=\"wpforms-18076-field_75_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_75_9\">Hand Tremors<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_75_10\" name=\"wpforms[fields][75][]\" value=\"Swelling in Legs or Ankles\" aria-errormessage=\"wpforms-18076-field_75_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_75_10\">Swelling in Legs or Ankles<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_75_11\" name=\"wpforms[fields][75][]\" value=\"Balance Problems\" aria-errormessage=\"wpforms-18076-field_75_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_75_11\">Balance Problems<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_75_12\" name=\"wpforms[fields][75][]\" value=\"Vision or Hearing Issues\" aria-errormessage=\"wpforms-18076-field_75_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_75_12\">Vision or Hearing Issues<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_75_13\" name=\"wpforms[fields][75][]\" value=\"Dizziness\" aria-errormessage=\"wpforms-18076-field_75_13-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_75_13\">Dizziness<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_75_14\" name=\"wpforms[fields][75][]\" value=\"Nausea and Vomiting\" aria-errormessage=\"wpforms-18076-field_75_14-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_75_14\">Nausea and Vomiting<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_75_15\" name=\"wpforms[fields][75][]\" value=\"Localized Swelling\" aria-errormessage=\"wpforms-18076-field_75_15-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_75_15\">Localized Swelling<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_75_16\" name=\"wpforms[fields][75][]\" value=\"Bruising\" aria-errormessage=\"wpforms-18076-field_75_16-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_75_16\">Bruising<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_75_17\" name=\"wpforms[fields][75][]\" value=\"Bleeding History\" aria-errormessage=\"wpforms-18076-field_75_17-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_75_17\">Bleeding History<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_75_18\" name=\"wpforms[fields][75][]\" value=\"Muscle Pain\" aria-errormessage=\"wpforms-18076-field_75_18-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_75_18\">Muscle Pain<\/label><\/li><li class=\"choice-20 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_75_20\" name=\"wpforms[fields][75][]\" value=\"Tingling or Numbness in Hands or Feet\" aria-errormessage=\"wpforms-18076-field_75_20-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_75_20\">Tingling or Numbness in Hands or Feet<\/label><\/li><li class=\"choice-21 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_75_21\" name=\"wpforms[fields][75][]\" value=\"Muscle Weakness\" aria-errormessage=\"wpforms-18076-field_75_21-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_75_21\">Muscle Weakness<\/label><\/li><li class=\"choice-22 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_75_22\" name=\"wpforms[fields][75][]\" value=\"Non-healing Wounds\" aria-errormessage=\"wpforms-18076-field_75_22-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_75_22\">Non-healing Wounds<\/label><\/li><li class=\"choice-23 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_75_23\" name=\"wpforms[fields][75][]\" value=\"Abdominal Pain\" aria-errormessage=\"wpforms-18076-field_75_23-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_75_23\">Abdominal Pain<\/label><\/li><li class=\"choice-24 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_75_24\" name=\"wpforms[fields][75][]\" value=\"Back Pain\" aria-errormessage=\"wpforms-18076-field_75_24-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_75_24\">Back Pain<\/label><\/li><li class=\"choice-25 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_75_25\" name=\"wpforms[fields][75][]\" value=\"Neck Pain\" aria-errormessage=\"wpforms-18076-field_75_25-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_75_25\">Neck Pain<\/label><\/li><li class=\"choice-26 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_75_26\" name=\"wpforms[fields][75][]\" value=\"Urine Color Changes\" aria-errormessage=\"wpforms-18076-field_75_26-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_75_26\">Urine Color Changes<\/label><\/li><li class=\"choice-27 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_75_27\" name=\"wpforms[fields][75][]\" value=\"Stool Color Changes\" aria-errormessage=\"wpforms-18076-field_75_27-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_75_27\">Stool Color Changes<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-18076-field_81-container\" class=\"wpforms-field wpforms-field-number-slider wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"81\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_81\">Pain (rate severity from 1 to 10)<\/label>\n<input\n\ttype=\"range\"\n\tid=\"wpforms-18076-field_81\" class=\"wpforms-field-medium\" name=\"wpforms[fields][81]\" value=\"1\" aria-errormessage=\"wpforms-18076-field_81-error\"\t\tmin=\"1\"\n\tmax=\"10\"\n\tstep=\"1\">\n\n<div class=\"wpforms-field-number-slider-hint\"\n\tdata-hint=\"Selected Value: {value}\">\n\tSelected Value: <b>1<\/b><\/div>\n<\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-18076-field_83-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-modern\" data-field-id=\"83\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_83\">Weight Change  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-18076-field_83\" class=\"wpforms-field-medium wpforms-field-required choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][83]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'><\/option><option value=\"Increase\"  class=\"choice-1 depth-1\"  >Increase<\/option><option value=\"Decrease\"  class=\"choice-2 depth-1\"  >Decrease<\/option><option value=\"None\"  class=\"choice-3 depth-1\"  >None<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-18076-field_86-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"86\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Stool Changes  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-18076-field_86\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_86_1\" name=\"wpforms[fields][86][]\" value=\"Constipation\" aria-errormessage=\"wpforms-18076-field_86_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_86_1\">Constipation<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_86_2\" name=\"wpforms[fields][86][]\" value=\"Diarrhea\" aria-errormessage=\"wpforms-18076-field_86_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_86_2\">Diarrhea<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_86_3\" name=\"wpforms[fields][86][]\" value=\"Blood in Stool\" aria-errormessage=\"wpforms-18076-field_86_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_86_3\">Blood in Stool<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_86_4\" name=\"wpforms[fields][86][]\" value=\"None\" aria-errormessage=\"wpforms-18076-field_86_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_86_4\">None<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-18076-field_85-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"85\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_85\">Lump or Mass in the Body (specify location)<\/label><input type=\"text\" id=\"wpforms-18076-field_85\" class=\"wpforms-field-medium\" name=\"wpforms[fields][85]\" aria-errormessage=\"wpforms-18076-field_85-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-18076-field_87-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"87\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Excessive Fatigue <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-18076-field_87\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_87_1\" name=\"wpforms[fields][87][]\" value=\"Physical\" aria-errormessage=\"wpforms-18076-field_87_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_87_1\">Physical<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_87_2\" name=\"wpforms[fields][87][]\" value=\"Mental\" aria-errormessage=\"wpforms-18076-field_87_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_87_2\">Mental<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_87_5\" name=\"wpforms[fields][87][]\" value=\"None\" aria-errormessage=\"wpforms-18076-field_87_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_87_5\">None<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-18076-field_88-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"88\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_88\">Joint Pain (specify location)<\/label><input type=\"text\" id=\"wpforms-18076-field_88\" class=\"wpforms-field-medium\" name=\"wpforms[fields][88]\" aria-errormessage=\"wpforms-18076-field_88-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-18076-field_89-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"89\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_89\">Other Symptoms:<\/label><textarea id=\"wpforms-18076-field_89\" class=\"wpforms-field-medium\" name=\"wpforms[fields][89]\" aria-errormessage=\"wpforms-18076-field_89-error\" ><\/textarea><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><\/div><\/div><div id=\"wpforms-18076-field_90-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"90\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_90\">8.\tPrevious Illnesses: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-18076-field_90\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][90]\" aria-errormessage=\"wpforms-18076-field_90-error\" required><\/textarea><\/div><div id=\"wpforms-18076-field_91-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"91\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_91\">9.\tFamily History of Illness: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-18076-field_91\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][91]\" aria-errormessage=\"wpforms-18076-field_91-error\" required><\/textarea><\/div><div id=\"wpforms-18076-field_92-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"92\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\t10.\tSocial History:\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-18076-field_93-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"93\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_93\">Smoking (frequency and duration):<\/label><input type=\"text\" id=\"wpforms-18076-field_93\" class=\"wpforms-field-medium\" name=\"wpforms[fields][93]\" aria-errormessage=\"wpforms-18076-field_93-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-18076-field_94-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"94\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\"><\/legend><ul id=\"wpforms-18076-field_94\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_94_1\" name=\"wpforms[fields][94][]\" value=\"Alcohol Use\" aria-errormessage=\"wpforms-18076-field_94_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_94_1\">Alcohol Use<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_94_2\" name=\"wpforms[fields][94][]\" value=\"Drug Use\" aria-errormessage=\"wpforms-18076-field_94_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_94_2\">Drug Use<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_94_3\" name=\"wpforms[fields][94][]\" value=\"Recent Travel History\" aria-errormessage=\"wpforms-18076-field_94_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_94_3\">Recent Travel History<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_94_4\" name=\"wpforms[fields][94][]\" value=\"None\" aria-errormessage=\"wpforms-18076-field_94_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_94_4\">None<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-18076-field_95-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"95\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\t11. Mental Health:\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-18076-field_96-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"96\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_96\">Did you experience sadness or depression at the time of diagnosis? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-18076-field_96\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][96]\" aria-errormessage=\"wpforms-18076-field_96-error\" required><\/textarea><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-18076-field_97-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"97\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_97\">Did activities you previously enjoyed remain pleasurable? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-18076-field_97\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][97]\" aria-errormessage=\"wpforms-18076-field_97-error\" required><\/textarea><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-18076-field_98-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"98\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_98\">Did you experience stress or anxiety at diagnosis? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-18076-field_98\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][98]\" aria-errormessage=\"wpforms-18076-field_98-error\" required><\/textarea><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-18076-field_99-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"99\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_99\">Did you have thoughts of suicide, self-harm, or harm to others? If yes, were these thoughts acted upon? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-18076-field_99\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][99]\" aria-errormessage=\"wpforms-18076-field_99-error\" required><\/textarea><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-18076-field_100-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"100\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_100\">Did you experience decreased concentration? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-18076-field_100\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][100]\" aria-errormessage=\"wpforms-18076-field_100-error\" required><\/textarea><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-18076-field_101-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"101\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_101\">If you had symptoms such as seeing or hearing things others did not, please provide a detailed description here. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-18076-field_101\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][101]\" aria-errormessage=\"wpforms-18076-field_101-error\" required><\/textarea><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-18076-field_102-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"102\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_102\">Have you ever experienced excessive energy or overspending? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-18076-field_102\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][102]\" aria-errormessage=\"wpforms-18076-field_102-error\" required><\/textarea><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><\/div><\/div><div id=\"wpforms-18076-field_103-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"103\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_103\">12. Physician\u2019s Diagnosis: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-18076-field_103\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][103]\" aria-errormessage=\"wpforms-18076-field_103-error\" required><\/textarea><\/div><div id=\"wpforms-18076-field_104-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"104\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_104\">13. Prescribed Medications: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-18076-field_104\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][104]\" aria-errormessage=\"wpforms-18076-field_104-error\" required><\/textarea><\/div><div id=\"wpforms-18076-field_105-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"105\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_105\">14. Physician-ordered Radiology, Ultrasound, CT Scan, etc.: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-18076-field_105\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][105]\" aria-errormessage=\"wpforms-18076-field_105-error\" required><\/textarea><\/div><div id=\"wpforms-18076-field_106-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"106\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_106\">15. Hospitalization or Surgical History: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-18076-field_106\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][106]\" aria-errormessage=\"wpforms-18076-field_106-error\" required><\/textarea><\/div><div id=\"wpforms-18076-field_107-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"107\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_107\">16. Describe in detail any physical changes experienced during and after Faradarmani sessions. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-18076-field_107\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][107]\" aria-errormessage=\"wpforms-18076-field_107-error\" required><\/textarea><\/div><div id=\"wpforms-18076-field_109-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"109\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\t17. Types of Connections Used:\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-18076-field_110-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"110\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Choose Connection <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-18076-field_110\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_110_1\" name=\"wpforms[fields][110][]\" value=\"Faradarmani\" aria-errormessage=\"wpforms-18076-field_110_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_110_1\">Faradarmani<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_110_2\" name=\"wpforms[fields][110][]\" value=\"Tashasho Defaie (TD)\" aria-errormessage=\"wpforms-18076-field_110_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_110_2\">Tashasho Defaie (TD)<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_110_3\" name=\"wpforms[fields][110][]\" value=\"Zehn-e-eshteraki (Shared Mind)\" aria-errormessage=\"wpforms-18076-field_110_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_110_3\">Zehn-e-eshteraki (Shared Mind)<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-18076-field_111-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"111\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_111\">Other:<\/label><input type=\"text\" id=\"wpforms-18076-field_111\" class=\"wpforms-field-medium\" name=\"wpforms[fields][111]\" aria-errormessage=\"wpforms-18076-field_111-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><\/div><\/div>\t\t<div id=\"wpforms-18076-field_1-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"1\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-18076-field_1\" >mental Country 3.\tSeverity<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-18076-field_1\" class=\"wpforms-field-medium\" name=\"wpforms[fields][1]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-18076-field_108-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"108\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_108\">18. Describe in detail any psychological or mental changes experienced during and after Faradarmani sessions. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-18076-field_108\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][108]\" aria-errormessage=\"wpforms-18076-field_108-error\" required><\/textarea><\/div><div id=\"wpforms-18076-field_112-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"112\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_112\">19.\tPlease describe the therapeutic outcomes (according to physicians) following Faradarmani treatment: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-18076-field_112\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][112]\" aria-errormessage=\"wpforms-18076-field_112-error\" required><\/textarea><\/div><div id=\"wpforms-18076-field_40-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"40\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_40\">Addiction Type <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-18076-field_40\" class=\"wpforms-field-medium wpforms-field-required wpforms-limit-words-enabled\" data-form-id=\"18076\" data-field-id=\"40\" data-text-limit=\"5\" name=\"wpforms[fields][40]\" aria-errormessage=\"wpforms-18076-field_40-error\" required><\/div><div id=\"wpforms-18076-field_41-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"41\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_41\">Addiction Duration <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-18076-field_41\" class=\"wpforms-field-medium wpforms-field-required wpforms-limit-words-enabled\" data-form-id=\"18076\" data-field-id=\"41\" data-text-limit=\"5\" name=\"wpforms[fields][41]\" aria-errormessage=\"wpforms-18076-field_41-error\" required><\/div><div id=\"wpforms-18076-field_12-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"12\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_12\">Report Your Result <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-18076-field_12\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][12]\" aria-errormessage=\"wpforms-18076-field_12-error\" aria-describedby=\"wpforms-18076-field_12-description\" required><\/textarea><div id=\"wpforms-18076-field_12-description\" class=\"wpforms-field-description\">Briefly tell us about your treatment\/rehabitation experience. If you have any improvement, externalization or report, after using Connection, please briefly explain here.<\/div><\/div><div id=\"wpforms-18076-field_37-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"37\"><fieldset><legend class=\"wpforms-field-label\">Consent <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-18076-field_37\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-18076-field_37_1\" name=\"wpforms[fields][37][]\" value=\"I agree to voluntarily participate in consciousness fields researches.\" aria-errormessage=\"wpforms-18076-field_37_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-18076-field_37_1\">I agree to voluntarily participate in consciousness fields researches.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-18076-field_15-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-18076-field_15\">File Upload <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div\n\t\tclass=\"wpforms-uploader wpforms-field-required\"\n\t\tdata-field-id=\"15\"\n\t\tdata-form-id=\"18076\"\n\t\tdata-input-name=\"wpforms_18076_15\"\n\t\tdata-extensions=\"pdf,zip,jpg\"\n\t\tdata-max-size=\"6291456\"\n\t\tdata-max-file-number=\"4\"\n\t\tdata-post-max-size=\"1073741824\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg  viewBox=\"0 0 640 640\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M352 173.3L352 384C352 401.7 337.7 416 320 416C302.3 416 288 401.7 288 384L288 173.3L246.6 214.7C234.1 227.2 213.8 227.2 201.3 214.7C188.8 202.2 188.8 181.9 201.3 169.4L297.3 73.4C309.8 60.9 330.1 60.9 342.6 73.4L438.6 169.4C451.1 181.9 451.1 202.2 438.6 214.7C426.1 227.2 405.8 227.2 393.3 214.7L352 173.3zM320 464C364.2 464 400 428.2 400 384L480 384C515.3 384 544 412.7 544 448L544 480C544 515.3 515.3 544 480 544L160 544C124.7 544 96 515.3 96 480L96 448C96 412.7 124.7 384 160 384L240 384C240 428.2 275.8 464 320 464zM464 488C477.3 488 488 477.3 488 464C488 450.7 477.3 440 464 440C450.7 440 440 450.7 440 464C440 477.3 450.7 488 464 488z\"\/>\n\t\t<\/svg>\n\n\t\t<span class=\"modern-title\">\n\t\t\t\t\t\t\tDrag &amp; Drop Files, \t\t\t\t<span>Choose Files to Upload<\/span>\n\t\t\t\t\t<\/span>\n\n\t\t\t\t\t<span class=\"modern-hint\">You can upload up to 4 files.<\/span>\n\t\t\t<\/div>\n<\/div>\n\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-18076-field_15\"\n\t\tname=\"wpforms_18076_15\" required\t\tvalue=\"\">\n<div id=\"wpforms-18076-field_15-description\" class=\"wpforms-field-description\">Please upload your medical report before and after treatment. To make the documents usable for research, your full name must be clearly stated on the submitted document. All your information will be kept confidential at the CosmoIntel Research Institute. These documents might be used for the research purposes.  Max File Size 6 MB. (PDF, zip, .jpg)<\/div><\/div><div id=\"wpforms-18076-field_113-container\" class=\"wpforms-field wpforms-field-content wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"113\" style=\"display:none;\"><div id=\"wpforms-18076-field_113\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-18076-field_113-error\"><ul>\n<li><span style=\"color:#ff0000\"><strong>Note: <\/strong><\/span><span style=\"color:#ffffff\">To support scientific goals, all details you provide will remain confidential with the Faradarmani Medical Research Department. Please, as far as possible, submit all documents from before, during, and after treatment for scientific evaluation. All submitted documents should be labelled with your full name and date, including the required records as outlined above.<\/span><\/li>\n<\/ul>\n<p><span style=\"font-size:12px\"><span style=\"color:#ffcc00\">Thank you for your cooperation and\u00a0 assistance,<br \/>\n<\/span><span style=\"color:#ffcc00\">Faradarmani Medical Research Department.<\/span><\/span><\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-18076-field_1-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-18076-field_1-container input { visibility: hidden; } #wpforms-conversational-form-page #wpforms-18076-field_1-container label { counter-increment: none; }' ) );\n\t\t\t\t\tdocument.head.appendChild( style );\n\t\t\t\t\tdocument.currentScript?.remove();\n\t\t\t\t} )();\n\t\t\t<\/script><\/div><!-- .wpforms-field-container -->\r\n\t\t\t<script>\r\n\t\t\tif ( typeof huOptions !== 'undefined' ) {\r\n\t\t\t\tvar huFormData = {\"source\":\"wpforms\",\"id\":18076,\"title\":\"Submit Your Treatment or Rehabition Report\",\"fields\":{\"subject\":{\"first_name\":\"\",\"last_name\":\"\"}}};\r\n\t\t\t\tvar huFormNode = document.querySelector( '[id=\"wpforms-18076\"] form' );\r\n\r\n\t\t\t\tvar firstName = huFormNode.querySelector( 'input.wpforms-field-name-first' );\r\n\t\t\t\tvar lastName = huFormNode.querySelector( 'input.wpforms-field-name-last' );\r\n\r\n\t\t\t\tif ( firstName )\r\n\t\t\t\t\thuFormData['fields']['subject']['first_name'] = firstName.getAttribute( 'name' );\r\n\r\n\t\t\t\tif ( lastName )\r\n\t\t\t\t\thuFormData['fields']['subject']['last_name'] = lastName.getAttribute( 'name' );\r\n\r\n\t\t\t\thuFormData['node'] = huFormNode;\r\n\t\t\t\thuOptions['forms'].push( huFormData );\r\n\t\t\t}\r\n\t\t\t<\/script><div class=\"wpforms-recaptcha-container wpforms-is-hcaptcha\" ><div class=\"h-captcha\" data-sitekey=\"1bc3923c-88ac-4b84-a632-13bbc2c95206\"><\/div><input type=\"text\" name=\"g-recaptcha-hidden\" class=\"wpforms-recaptcha-hidden\" style=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\" data-rule-hcaptcha=\"1\"><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"18076\"><input type=\"hidden\" name=\"page_title\" value=\"Treatment Report\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/cosmointel.com\/treatment-report\/\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><input type=\"hidden\" name=\"page_id\" value=\"18128\"><input type=\"hidden\" name=\"wpforms[post_id]\" value=\"18128\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-18076\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><\/div><\/form><\/div>  <!-- .wpforms-container --><\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-e2a4260 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"e2a4260\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-964b67c\" data-id=\"964b67c\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-4276db4 elementor-widget elementor-widget-spacer\" data-id=\"4276db4\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Since our main goal is to help patients and those who are affected by addiction to quit, we encourage you to submit your treatment report and\/or your rehabilitation experience, using Connection to Cosmic Internet. Hence, if you have requested for the Connection before and improved successfully, you can submit your report and medical documents now.&#8230;<\/p>","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-18128","page","type-page","status-publish","hentry"],"aioseo_notices":[],"jetpack_shortlink":"https:\/\/wp.me\/PcE7gY-4Io","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/cosmointel.com\/fa\/wp-json\/wp\/v2\/pages\/18128","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/cosmointel.com\/fa\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/cosmointel.com\/fa\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/cosmointel.com\/fa\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/cosmointel.com\/fa\/wp-json\/wp\/v2\/comments?post=18128"}],"version-history":[{"count":0,"href":"https:\/\/cosmointel.com\/fa\/wp-json\/wp\/v2\/pages\/18128\/revisions"}],"wp:attachment":[{"href":"https:\/\/cosmointel.com\/fa\/wp-json\/wp\/v2\/media?parent=18128"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}