{"id":288,"date":"2024-02-12T06:41:27","date_gmt":"2024-02-12T06:41:27","guid":{"rendered":"https:\/\/new.samev-dz.com\/?page_id=288"},"modified":"2024-02-12T06:41:56","modified_gmt":"2024-02-12T06:41:56","slug":"fiche-avc-mode-dentree-dans-la-maladie","status":"publish","type":"page","link":"https:\/\/new.samev-dz.com\/index.php\/fiche-avc-mode-dentree-dans-la-maladie\/","title":{"rendered":"Fiche AVC (Mode d\u2019entr\u00e9e dans la maladie)"},"content":{"rendered":"<p><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1456px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-1\"><p><b>\u00a0<\/b><\/p>\n<\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1456px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-287 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-287\" data-uid=\"69e074ac78ace\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-287\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-287 forminator-design--default  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"287\"\n\t\t\t\t data-color-option=\"default\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"69e074ac78ace\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_69e074ac78ace\" id=\"forminator-field-name-1_69e074ac78ace-label\" class=\"forminator-label\">Nom <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_69e074ac78ace\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_69e074ac78ace\" id=\"forminator-field-name-2_69e074ac78ace-label\" class=\"forminator-label\">Pr\u00e9nom <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"\" id=\"forminator-field-name-2_69e074ac78ace\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_69e074ac78ace\" id=\"forminator-field-text-2_69e074ac78ace-label\" class=\"forminator-label\">Age <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_69e074ac78ace\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-1-69e074ac78ace-label\"><span id=\"forminator-radiogroup-radio-1-69e074ac78ace-label\" class=\"forminator-label\">Sexe <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-69e074ac78ace\" class=\"forminator-radio forminator-radio-inline\" title=\"Homme\"><input type=\"radio\" name=\"radio-1\" value=\"one\" id=\"forminator-field-radio-1-1-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-1-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Homme<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-69e074ac78ace\" class=\"forminator-radio forminator-radio-inline\" title=\"Femme\"><input type=\"radio\" name=\"radio-1\" value=\"two\" id=\"forminator-field-radio-1-2-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-1-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Femme<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-1-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-street_address_69e074ac78ace\" id=\"forminator-field-address-1-street_address_69e074ac78ace-label\" class=\"forminator-label\">Adresse<\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"\" id=\"forminator-field-address-1-street_address_69e074ac78ace\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line1\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_69e074ac78ace\" id=\"forminator-field-date-1-picker_69e074ac78ace-label\" class=\"forminator-label\">Date d\u2019entr\u00e9e ou date de consultation ou date du diagnostic <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"\" id=\"forminator-field-date-1-picker_69e074ac78ace\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"dd-mm-yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker_69e074ac78ace\" id=\"forminator-field-date-2-picker_69e074ac78ace-label\" class=\"forminator-label\">Date de sortie<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-2\" value=\"\" placeholder=\"\" id=\"forminator-field-date-2-picker_69e074ac78ace\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd-mm-yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-2\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-2-69e074ac78ace-label\"><span id=\"forminator-radiogroup-radio-2-69e074ac78ace-label\" class=\"forminator-label\">Circonstance d\u2019admission <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-2-label-1\" for=\"forminator-field-radio-2-1-69e074ac78ace\" class=\"forminator-radio\" title=\"1.\tAccompagn\u00e9 par un parent\"><input type=\"radio\" name=\"radio-2\" value=\"one\" id=\"forminator-field-radio-2-1-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-2-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">1.\tAccompagn\u00e9 par un parent<\/span><\/label><label id=\"forminator-field-radio-2-label-2\" for=\"forminator-field-radio-2-2-69e074ac78ace\" class=\"forminator-radio\" title=\"2.\tEvacuation d\u2019une autre structure\"><input type=\"radio\" name=\"radio-2\" value=\"two\" id=\"forminator-field-radio-2-2-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-2-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">2.\tEvacuation d\u2019une autre structure<\/span><\/label><label id=\"forminator-field-radio-2-label-3\" for=\"forminator-field-radio-2-3-69e074ac78ace\" class=\"forminator-radio\" title=\"3.\tEvacuation par le SAMU\"><input type=\"radio\" name=\"radio-2\" value=\"3.-Evacuation-par-le-SAMU\" id=\"forminator-field-radio-2-3-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-2-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">3.\tEvacuation par le SAMU<\/span><\/label><label id=\"forminator-field-radio-2-label-4\" for=\"forminator-field-radio-2-4-69e074ac78ace\" class=\"forminator-radio\" title=\"4.\tEvacuation par la Protection civile\"><input type=\"radio\" name=\"radio-2\" value=\"4.-Evacuation-par-la-Protection-civile\" id=\"forminator-field-radio-2-4-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-2-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">4.\tEvacuation par la Protection civile<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_69e074ac78ace\" id=\"forminator-field-text-5_69e074ac78ace-label\" class=\"forminator-label\">l&#039;ancienne structure <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5_69e074ac78ace\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-6 \"><div role=\"group\" class=\"forminator-field required\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-1-69e074ac78ace-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-1-69e074ac78ace-label\" class=\"forminator-label\">HTA <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-checkbox-1-1-69e074ac78ace-label\" for=\"forminator-field-checkbox-1-1-69e074ac78ace\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Oui\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"one\" id=\"forminator-field-checkbox-1-1-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-1-1-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Oui<\/span><\/label><label id=\"forminator-field-checkbox-1-2-69e074ac78ace-label\" for=\"forminator-field-checkbox-1-2-69e074ac78ace\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Non\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Non\" id=\"forminator-field-checkbox-1-2-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-1-2-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Non<\/span><\/label><\/div><\/div><div id=\"date-3\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-3-picker_69e074ac78ace\" id=\"forminator-field-date-3-picker_69e074ac78ace-label\" class=\"forminator-label\">Date de Diagnostic<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-3\" value=\"\" placeholder=\"\" id=\"forminator-field-date-3-picker_69e074ac78ace\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd-mm-yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-19\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-19-69e074ac78ace-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-19-69e074ac78ace-label\" class=\"forminator-label\">HTA \u00e9quilibr\u00e9e<\/span><label id=\"forminator-field-checkbox-19-1-69e074ac78ace-label\" for=\"forminator-field-checkbox-19-1-69e074ac78ace\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Oui\"><input type=\"checkbox\" name=\"checkbox-19[]\" value=\"one\" id=\"forminator-field-checkbox-19-1-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-19-1-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Oui<\/span><\/label><label id=\"forminator-field-checkbox-19-2-69e074ac78ace-label\" for=\"forminator-field-checkbox-19-2-69e074ac78ace\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Non\"><input type=\"checkbox\" name=\"checkbox-19[]\" value=\"Non\" id=\"forminator-field-checkbox-19-2-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-19-2-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Non<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-15\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-15-69e074ac78ace-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-15-69e074ac78ace-label\" class=\"forminator-label\">HTA d\u00e9pist\u00e9e lors de l&#039;AVC<\/span><label id=\"forminator-field-checkbox-15-1-69e074ac78ace-label\" for=\"forminator-field-checkbox-15-1-69e074ac78ace\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Oui\"><input type=\"checkbox\" name=\"checkbox-15[]\" value=\"one\" id=\"forminator-field-checkbox-15-1-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-15-1-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Oui<\/span><\/label><label id=\"forminator-field-checkbox-15-2-69e074ac78ace-label\" for=\"forminator-field-checkbox-15-2-69e074ac78ace\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Non\"><input type=\"checkbox\" name=\"checkbox-15[]\" value=\"Non\" id=\"forminator-field-checkbox-15-2-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-15-2-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Non<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-16\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-16-69e074ac78ace-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-16-69e074ac78ace-label\" class=\"forminator-label\">HTA trait\u00e9e<\/span><label id=\"forminator-field-checkbox-16-1-69e074ac78ace-label\" for=\"forminator-field-checkbox-16-1-69e074ac78ace\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Oui\"><input type=\"checkbox\" name=\"checkbox-16[]\" value=\"one\" id=\"forminator-field-checkbox-16-1-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-16-1-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Oui<\/span><\/label><label id=\"forminator-field-checkbox-16-2-69e074ac78ace-label\" for=\"forminator-field-checkbox-16-2-69e074ac78ace\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Non\"><input type=\"checkbox\" name=\"checkbox-16[]\" value=\"Non\" id=\"forminator-field-checkbox-16-2-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-16-2-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Non<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-8\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-8-69e074ac78ace-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-8-69e074ac78ace-label\" class=\"forminator-label\">Traitement<\/span><label id=\"forminator-field-checkbox-8-1-69e074ac78ace-label\" for=\"forminator-field-checkbox-8-1-69e074ac78ace\" class=\"forminator-checkbox\" title=\"ARA II\"><input type=\"checkbox\" name=\"checkbox-8[]\" value=\"one\" id=\"forminator-field-checkbox-8-1-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-8-1-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">ARA II<\/span><\/label><label id=\"forminator-field-checkbox-8-2-69e074ac78ace-label\" for=\"forminator-field-checkbox-8-2-69e074ac78ace\" class=\"forminator-checkbox\" title=\"IEC\"><input type=\"checkbox\" name=\"checkbox-8[]\" value=\"Oui\" id=\"forminator-field-checkbox-8-2-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-8-2-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">IEC<\/span><\/label><label id=\"forminator-field-checkbox-8-3-69e074ac78ace-label\" for=\"forminator-field-checkbox-8-3-69e074ac78ace\" class=\"forminator-checkbox\" title=\"B.Bloquants\"><input type=\"checkbox\" name=\"checkbox-8[]\" value=\"B.Bloquants\" id=\"forminator-field-checkbox-8-3-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-8-3-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">B.Bloquants<\/span><\/label><label id=\"forminator-field-checkbox-8-4-69e074ac78ace-label\" for=\"forminator-field-checkbox-8-4-69e074ac78ace\" class=\"forminator-checkbox\" title=\"I. Calciques\"><input type=\"checkbox\" name=\"checkbox-8[]\" value=\"I.-Calciques\" id=\"forminator-field-checkbox-8-4-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-8-4-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I. Calciques<\/span><\/label><label id=\"forminator-field-checkbox-8-5-69e074ac78ace-label\" for=\"forminator-field-checkbox-8-5-69e074ac78ace\" class=\"forminator-checkbox\" title=\"Anti HTA  centraux\"><input type=\"checkbox\" name=\"checkbox-8[]\" value=\"Anti-HTA-centraux\" id=\"forminator-field-checkbox-8-5-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-8-5-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Anti HTA  centraux<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-27\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-27-69e074ac78ace-label\"><span id=\"forminator-radiogroup-radio-27-69e074ac78ace-label\" class=\"forminator-label\">Diab\u00e8te <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-27-label-1\" for=\"forminator-field-radio-27-1-69e074ac78ace\" class=\"forminator-radio forminator-radio-inline\" title=\"Oui\"><input type=\"radio\" name=\"radio-27\" value=\"one\" id=\"forminator-field-radio-27-1-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-27-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-27-label-2\" for=\"forminator-field-radio-27-2-69e074ac78ace\" class=\"forminator-radio forminator-radio-inline\" title=\"Non\"><input type=\"radio\" name=\"radio-27\" value=\"two\" id=\"forminator-field-radio-27-2-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-27-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"date-4\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-4-picker_69e074ac78ace\" id=\"forminator-field-date-4-picker_69e074ac78ace-label\" class=\"forminator-label\">Date de Diagnostic<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-4\" value=\"\" placeholder=\"\" id=\"forminator-field-date-4-picker_69e074ac78ace\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd-mm-yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-29\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-29-69e074ac78ace-label\"><span id=\"forminator-radiogroup-radio-29-69e074ac78ace-label\" class=\"forminator-label\">Type<\/span><label id=\"forminator-field-radio-29-label-1\" for=\"forminator-field-radio-29-1-69e074ac78ace\" class=\"forminator-radio forminator-radio-inline\" title=\"Type 1\"><input type=\"radio\" name=\"radio-29\" value=\"one\" id=\"forminator-field-radio-29-1-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-29-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Type 1<\/span><\/label><label id=\"forminator-field-radio-29-label-2\" for=\"forminator-field-radio-29-2-69e074ac78ace\" class=\"forminator-radio forminator-radio-inline\" title=\"Type 2\"><input type=\"radio\" name=\"radio-29\" value=\"two\" id=\"forminator-field-radio-29-2-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-29-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Type 2<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-28\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-28-69e074ac78ace-label\"><span id=\"forminator-radiogroup-radio-28-69e074ac78ace-label\" class=\"forminator-label\">Equilibr\u00e9<\/span><label id=\"forminator-field-radio-28-label-1\" for=\"forminator-field-radio-28-1-69e074ac78ace\" class=\"forminator-radio forminator-radio-inline\" title=\"Oui\"><input type=\"radio\" name=\"radio-28\" value=\"one\" id=\"forminator-field-radio-28-1-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-28-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-28-label-2\" for=\"forminator-field-radio-28-2-69e074ac78ace\" class=\"forminator-radio forminator-radio-inline\" title=\"Non\"><input type=\"radio\" name=\"radio-28\" value=\"two\" id=\"forminator-field-radio-28-2-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-28-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"text-32\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-32_69e074ac78ace\" id=\"forminator-field-text-32_69e074ac78ace-label\" class=\"forminator-label\">hba1c<\/label><input type=\"text\" name=\"text-32\" value=\"\" placeholder=\"\" id=\"forminator-field-text-32_69e074ac78ace\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-20\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-20-69e074ac78ace-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-20-69e074ac78ace-label\" class=\"forminator-label\">Diab\u00e8te d\u00e9pist\u00e9 lors de l&#039;AVC<\/span><label id=\"forminator-field-checkbox-20-1-69e074ac78ace-label\" for=\"forminator-field-checkbox-20-1-69e074ac78ace\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Oui\"><input type=\"checkbox\" name=\"checkbox-20[]\" value=\"one\" id=\"forminator-field-checkbox-20-1-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-20-1-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Oui<\/span><\/label><label id=\"forminator-field-checkbox-20-2-69e074ac78ace-label\" for=\"forminator-field-checkbox-20-2-69e074ac78ace\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"Non\"><input type=\"checkbox\" name=\"checkbox-20[]\" value=\"Non\" id=\"forminator-field-checkbox-20-2-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-20-2-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Non<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-30\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-30-69e074ac78ace-label\"><span id=\"forminator-radiogroup-radio-30-69e074ac78ace-label\" class=\"forminator-label\">Trait\u00e9<\/span><label id=\"forminator-field-radio-30-label-1\" for=\"forminator-field-radio-30-1-69e074ac78ace\" class=\"forminator-radio forminator-radio-inline\" title=\"Oui\"><input type=\"radio\" name=\"radio-30\" value=\"one\" id=\"forminator-field-radio-30-1-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-30-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-30-label-2\" for=\"forminator-field-radio-30-2-69e074ac78ace\" class=\"forminator-radio forminator-radio-inline\" title=\"Non\"><input type=\"radio\" name=\"radio-30\" value=\"two\" id=\"forminator-field-radio-30-2-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-30-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-21\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-21-69e074ac78ace-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-21-69e074ac78ace-label\" class=\"forminator-label\">Traitement<\/span><label id=\"forminator-field-checkbox-21-1-69e074ac78ace-label\" for=\"forminator-field-checkbox-21-1-69e074ac78ace\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"antidiab\u00e9tiques oraux\"><input type=\"checkbox\" name=\"checkbox-21[]\" value=\"one\" id=\"forminator-field-checkbox-21-1-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-21-1-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">antidiab\u00e9tiques oraux<\/span><\/label><label id=\"forminator-field-checkbox-21-2-69e074ac78ace-label\" for=\"forminator-field-checkbox-21-2-69e074ac78ace\" class=\"forminator-checkbox forminator-checkbox-inline\" title=\"insulines\"><input type=\"checkbox\" name=\"checkbox-21[]\" value=\"Non\" id=\"forminator-field-checkbox-21-2-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-21-2-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">insulines<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-11\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-11-69e074ac78ace-label\"><span id=\"forminator-radiogroup-radio-11-69e074ac78ace-label\" class=\"forminator-label\">Tabagisme <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-11-label-1\" for=\"forminator-field-radio-11-1-69e074ac78ace\" class=\"forminator-radio forminator-radio-inline\" title=\"Oui\"><input type=\"radio\" name=\"radio-11\" value=\"one\" id=\"forminator-field-radio-11-1-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-11-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-11-label-2\" for=\"forminator-field-radio-11-2-69e074ac78ace\" class=\"forminator-radio forminator-radio-inline\" title=\"Non\"><input type=\"radio\" name=\"radio-11\" value=\"two\" id=\"forminator-field-radio-11-2-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-11-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"date-5\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-5-picker_69e074ac78ace\" id=\"forminator-field-date-5-picker_69e074ac78ace-label\" class=\"forminator-label\">Date de d\u00e9but<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-5\" value=\"\" placeholder=\"\" id=\"forminator-field-date-5-picker_69e074ac78ace\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd-mm-yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-11\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-11_69e074ac78ace\" id=\"forminator-field-text-11_69e074ac78ace-label\" class=\"forminator-label\">Dur\u00e9e<\/label><input type=\"text\" name=\"text-11\" value=\"\" placeholder=\"\" id=\"forminator-field-text-11_69e074ac78ace\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-25\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-25-69e074ac78ace-label\"><span id=\"forminator-radiogroup-radio-25-69e074ac78ace-label\" class=\"forminator-label\">Sevr\u00e9 <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-25-label-1\" for=\"forminator-field-radio-25-1-69e074ac78ace\" class=\"forminator-radio forminator-radio-inline\" title=\"Oui\"><input type=\"radio\" name=\"radio-25\" value=\"one\" id=\"forminator-field-radio-25-1-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-25-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-25-label-2\" for=\"forminator-field-radio-25-2-69e074ac78ace\" class=\"forminator-radio forminator-radio-inline\" title=\"Non\"><input type=\"radio\" name=\"radio-25\" value=\"two\" id=\"forminator-field-radio-25-2-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-25-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"text-13\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-13_69e074ac78ace\" id=\"forminator-field-text-13_69e074ac78ace-label\" class=\"forminator-label\">Dur\u00e9e<\/label><input type=\"text\" name=\"text-13\" value=\"\" placeholder=\"\" id=\"forminator-field-text-13_69e074ac78ace\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-3\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-3\"><label class=\"forminator-label\">Surpoids et ob\u00e9sit\u00e9<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-14\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-14_69e074ac78ace\" id=\"forminator-field-text-14_69e074ac78ace-label\" class=\"forminator-label\">Poids kg <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-14\" value=\"\" placeholder=\"\" id=\"forminator-field-text-14_69e074ac78ace\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><div id=\"text-15\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-15_69e074ac78ace\" id=\"forminator-field-text-15_69e074ac78ace-label\" class=\"forminator-label\">Taille ( m\u00e8tre ) <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-15\" value=\"\" placeholder=\"\" id=\"forminator-field-text-15_69e074ac78ace\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-16\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-16_69e074ac78ace\" id=\"forminator-field-text-16_69e074ac78ace-label\" class=\"forminator-label\">BMI <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-16\" value=\"\" placeholder=\"\" id=\"forminator-field-text-16_69e074ac78ace\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-17\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-17_69e074ac78ace\" id=\"forminator-field-text-17_69e074ac78ace-label\" class=\"forminator-label\">Tour de taille <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-17\" value=\"\" placeholder=\"\" id=\"forminator-field-text-17_69e074ac78ace\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-12\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-12-69e074ac78ace-label\"><span id=\"forminator-radiogroup-radio-12-69e074ac78ace-label\" class=\"forminator-label\">Dyslipid\u00e9mie <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-12-label-1\" for=\"forminator-field-radio-12-1-69e074ac78ace\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-12\" value=\"one\" id=\"forminator-field-radio-12-1-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-12-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-12-label-2\" for=\"forminator-field-radio-12-2-69e074ac78ace\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-12\" value=\"two\" id=\"forminator-field-radio-12-2-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-12-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-3\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-3-69e074ac78ace-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-3-69e074ac78ace-label\" class=\"forminator-label\">Type de dyslipid\u00e9mie<\/span><label id=\"forminator-field-checkbox-3-1-69e074ac78ace-label\" for=\"forminator-field-checkbox-3-1-69e074ac78ace\" class=\"forminator-checkbox\" title=\"LDL \u00e9lev\u00e9\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"one\" id=\"forminator-field-checkbox-3-1-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-3-1-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">LDL \u00e9lev\u00e9<\/span><\/label><label id=\"forminator-field-checkbox-3-2-69e074ac78ace-label\" for=\"forminator-field-checkbox-3-2-69e074ac78ace\" class=\"forminator-checkbox\" title=\"HDL bas\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"fibrates\" id=\"forminator-field-checkbox-3-2-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-3-2-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">HDL bas<\/span><\/label><label id=\"forminator-field-checkbox-3-3-69e074ac78ace-label\" for=\"forminator-field-checkbox-3-3-69e074ac78ace\" class=\"forminator-checkbox\" title=\"TG \u00e9lev\u00e9s\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"autres\" id=\"forminator-field-checkbox-3-3-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-3-3-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">TG \u00e9lev\u00e9s<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-22\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-22-69e074ac78ace-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-22-69e074ac78ace-label\" class=\"forminator-label\">Traitement<\/span><label id=\"forminator-field-checkbox-22-1-69e074ac78ace-label\" for=\"forminator-field-checkbox-22-1-69e074ac78ace\" class=\"forminator-checkbox\" title=\"Statines\"><input type=\"checkbox\" name=\"checkbox-22[]\" value=\"one\" id=\"forminator-field-checkbox-22-1-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-22-1-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Statines<\/span><\/label><label id=\"forminator-field-checkbox-22-2-69e074ac78ace-label\" for=\"forminator-field-checkbox-22-2-69e074ac78ace\" class=\"forminator-checkbox\" title=\"Fibrates\"><input type=\"checkbox\" name=\"checkbox-22[]\" value=\"fibrates\" id=\"forminator-field-checkbox-22-2-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-22-2-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Fibrates<\/span><\/label><label id=\"forminator-field-checkbox-22-3-69e074ac78ace-label\" for=\"forminator-field-checkbox-22-3-69e074ac78ace\" class=\"forminator-checkbox\" title=\"Autres\"><input type=\"checkbox\" name=\"checkbox-22[]\" value=\"autres\" id=\"forminator-field-checkbox-22-3-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-22-3-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Autres<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-9\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-9-69e074ac78ace-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-9-69e074ac78ace-label\" class=\"forminator-label\">Ant\u00e9c\u00e9dents de pathologies vasculaires<\/span><label id=\"forminator-field-checkbox-9-1-69e074ac78ace-label\" for=\"forminator-field-checkbox-9-1-69e074ac78ace\" class=\"forminator-checkbox\" title=\"Ant\u00e9c\u00e9dents d\u2019AVC\"><input type=\"checkbox\" name=\"checkbox-9[]\" value=\"one\" id=\"forminator-field-checkbox-9-1-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-9-1-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Ant\u00e9c\u00e9dents d\u2019AVC<\/span><\/label><label id=\"forminator-field-checkbox-9-2-69e074ac78ace-label\" for=\"forminator-field-checkbox-9-2-69e074ac78ace\" class=\"forminator-checkbox\" title=\"Ant\u00e9c\u00e9dents d\u2019AIT\"><input type=\"checkbox\" name=\"checkbox-9[]\" value=\"two\" id=\"forminator-field-checkbox-9-2-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-9-2-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Ant\u00e9c\u00e9dents d\u2019AIT<\/span><\/label><label id=\"forminator-field-checkbox-9-3-69e074ac78ace-label\" for=\"forminator-field-checkbox-9-3-69e074ac78ace\" class=\"forminator-checkbox\" title=\"Ant\u00e9c\u00e9dents d\u2019IDM\"><input type=\"checkbox\" name=\"checkbox-9[]\" value=\"Ant\u00e9c\u00e9dents-d\u2019IDM-:\" id=\"forminator-field-checkbox-9-3-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-9-3-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Ant\u00e9c\u00e9dents d\u2019IDM<\/span><\/label><label id=\"forminator-field-checkbox-9-4-69e074ac78ace-label\" for=\"forminator-field-checkbox-9-4-69e074ac78ace\" class=\"forminator-checkbox\" title=\"Ant\u00e9c\u00e9dents d\u2019AOMI\"><input type=\"checkbox\" name=\"checkbox-9[]\" value=\"Ant\u00e9c\u00e9dents-d\u2019Art\u00e9riopathies\" id=\"forminator-field-checkbox-9-4-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-9-4-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Ant\u00e9c\u00e9dents d\u2019AOMI<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-31\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-31-69e074ac78ace-label\"><span id=\"forminator-radiogroup-radio-31-69e074ac78ace-label\" class=\"forminator-label\">Fibrillation auriculaire <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-31-label-1\" for=\"forminator-field-radio-31-1-69e074ac78ace\" class=\"forminator-radio forminator-radio-inline\" title=\"Oui\"><input type=\"radio\" name=\"radio-31\" value=\"one\" id=\"forminator-field-radio-31-1-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-31-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-31-label-2\" for=\"forminator-field-radio-31-2-69e074ac78ace\" class=\"forminator-radio forminator-radio-inline\" title=\"Non\"><input type=\"radio\" name=\"radio-31\" value=\"two\" id=\"forminator-field-radio-31-2-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-31-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"date-6\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-6-picker_69e074ac78ace\" id=\"forminator-field-date-6-picker_69e074ac78ace-label\" class=\"forminator-label\">Date de Diagnostic<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-6\" value=\"\" placeholder=\"\" id=\"forminator-field-date-6-picker_69e074ac78ace\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd-mm-yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-22\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-22-69e074ac78ace-label\"><span id=\"forminator-radiogroup-radio-22-69e074ac78ace-label\" class=\"forminator-label\">Suivi <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-22-label-1\" for=\"forminator-field-radio-22-1-69e074ac78ace\" class=\"forminator-radio forminator-radio-inline\" title=\"Oui\"><input type=\"radio\" name=\"radio-22\" value=\"one\" id=\"forminator-field-radio-22-1-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-22-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-22-label-2\" for=\"forminator-field-radio-22-2-69e074ac78ace\" class=\"forminator-radio forminator-radio-inline\" title=\"Non\"><input type=\"radio\" name=\"radio-22\" value=\"two\" id=\"forminator-field-radio-22-2-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-22-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-6\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-6-69e074ac78ace-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-6-69e074ac78ace-label\" class=\"forminator-label\">Traitement<\/span><label id=\"forminator-field-checkbox-6-1-69e074ac78ace-label\" for=\"forminator-field-checkbox-6-1-69e074ac78ace\" class=\"forminator-checkbox\" title=\"AVK\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"one\" id=\"forminator-field-checkbox-6-1-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-6-1-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">AVK<\/span><\/label><label id=\"forminator-field-checkbox-6-2-69e074ac78ace-label\" for=\"forminator-field-checkbox-6-2-69e074ac78ace\" class=\"forminator-checkbox\" title=\"AOD\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"two\" id=\"forminator-field-checkbox-6-2-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-6-2-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">AOD<\/span><\/label><label id=\"forminator-field-checkbox-6-3-69e074ac78ace-label\" for=\"forminator-field-checkbox-6-3-69e074ac78ace\" class=\"forminator-checkbox\" title=\"aspirine\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"aspirine\" id=\"forminator-field-checkbox-6-3-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-6-3-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">aspirine<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-19\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-19-69e074ac78ace-label\"><span id=\"forminator-radiogroup-radio-19-69e074ac78ace-label\" class=\"forminator-label\">Autres Cardiopathies : <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-19-label-1\" for=\"forminator-field-radio-19-1-69e074ac78ace\" class=\"forminator-radio forminator-radio-inline\" title=\"Oui\"><input type=\"radio\" name=\"radio-19\" value=\"one\" id=\"forminator-field-radio-19-1-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-19-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-19-label-2\" for=\"forminator-field-radio-19-2-69e074ac78ace\" class=\"forminator-radio forminator-radio-inline\" title=\"Non\"><input type=\"radio\" name=\"radio-19\" value=\"two\" id=\"forminator-field-radio-19-2-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-19-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"text-20\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-20_69e074ac78ace\" id=\"forminator-field-text-20_69e074ac78ace-label\" class=\"forminator-label\">Type <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-20\" value=\"\" placeholder=\"\" id=\"forminator-field-text-20_69e074ac78ace\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-21\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-21-69e074ac78ace-label\"><span id=\"forminator-radiogroup-radio-21-69e074ac78ace-label\" class=\"forminator-label\">Autres affections associ\u00e9es : <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-21-label-1\" for=\"forminator-field-radio-21-1-69e074ac78ace\" class=\"forminator-radio forminator-radio-inline\" title=\"Oui\"><input type=\"radio\" name=\"radio-21\" value=\"one\" id=\"forminator-field-radio-21-1-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-21-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-21-label-2\" for=\"forminator-field-radio-21-2-69e074ac78ace\" class=\"forminator-radio forminator-radio-inline\" title=\"Non\"><input type=\"radio\" name=\"radio-21\" value=\"two\" id=\"forminator-field-radio-21-2-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-21-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-21\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-21_69e074ac78ace\" id=\"forminator-field-text-21_69e074ac78ace-label\" class=\"forminator-label\">Type<\/label><input type=\"text\" name=\"text-21\" value=\"\" placeholder=\"\" id=\"forminator-field-text-21_69e074ac78ace\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-22\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-22_69e074ac78ace\" id=\"forminator-field-text-22_69e074ac78ace-label\" class=\"forminator-label\">Traitement<\/label><input type=\"text\" name=\"text-22\" value=\"\" placeholder=\"\" id=\"forminator-field-text-22_69e074ac78ace\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-26\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-26-69e074ac78ace-label\"><span id=\"forminator-radiogroup-radio-26-69e074ac78ace-label\" class=\"forminator-label\">Contraception orale <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-26-label-1\" for=\"forminator-field-radio-26-1-69e074ac78ace\" class=\"forminator-radio forminator-radio-inline\" title=\"Oui\"><input type=\"radio\" name=\"radio-26\" value=\"one\" id=\"forminator-field-radio-26-1-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-26-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-26-label-2\" for=\"forminator-field-radio-26-2-69e074ac78ace\" class=\"forminator-radio forminator-radio-inline\" title=\"Non\"><input type=\"radio\" name=\"radio-26\" value=\"two\" id=\"forminator-field-radio-26-2-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-26-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-23\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-23_69e074ac78ace\" id=\"forminator-field-text-23_69e074ac78ace-label\" class=\"forminator-label\">Dur\u00e9e<\/label><input type=\"text\" name=\"text-23\" value=\"\" placeholder=\"\" id=\"forminator-field-text-23_69e074ac78ace\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-4\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-4-69e074ac78ace-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-4-69e074ac78ace-label\" class=\"forminator-label\">Sympt\u00f4mes cliniques<\/span><label id=\"forminator-field-checkbox-4-1-69e074ac78ace-label\" for=\"forminator-field-checkbox-4-1-69e074ac78ace\" class=\"forminator-checkbox\" title=\"troubles neurosensoriels\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"one\" id=\"forminator-field-checkbox-4-1-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-4-1-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">troubles neurosensoriels<\/span><\/label><label id=\"forminator-field-checkbox-4-2-69e074ac78ace-label\" for=\"forminator-field-checkbox-4-2-69e074ac78ace\" class=\"forminator-checkbox\" title=\"d\u00e9ficit moteur\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"two\" id=\"forminator-field-checkbox-4-2-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-4-2-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">d\u00e9ficit moteur<\/span><\/label><label id=\"forminator-field-checkbox-4-3-69e074ac78ace-label\" for=\"forminator-field-checkbox-4-3-69e074ac78ace\" class=\"forminator-checkbox\" title=\"troubles de la d\u00e9glutition\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"H\u00e9morragie-intra-c\u00e9r\u00e9brale\" id=\"forminator-field-checkbox-4-3-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-4-3-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">troubles de la d\u00e9glutition<\/span><\/label><label id=\"forminator-field-checkbox-4-4-69e074ac78ace-label\" for=\"forminator-field-checkbox-4-4-69e074ac78ace\" class=\"forminator-checkbox\" title=\"troubles du langage\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"troubles-du-langage\" id=\"forminator-field-checkbox-4-4-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-4-4-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">troubles du langage<\/span><\/label><label id=\"forminator-field-checkbox-4-5-69e074ac78ace-label\" for=\"forminator-field-checkbox-4-5-69e074ac78ace\" class=\"forminator-checkbox\" title=\"convulsions\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"H\u00e9morragie-sous-arachno\u00efdienne\" id=\"forminator-field-checkbox-4-5-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-4-5-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">convulsions<\/span><\/label><label id=\"forminator-field-checkbox-4-6-69e074ac78ace-label\" for=\"forminator-field-checkbox-4-6-69e074ac78ace\" class=\"forminator-checkbox\" title=\"Troubles de la  conscience\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Troubles-de-la-conscience\" id=\"forminator-field-checkbox-4-6-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-4-6-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Troubles de la  conscience<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-7\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-7\"><label class=\"forminator-label\">Examens Radiologiques<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-23\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-23-69e074ac78ace-label\"><span id=\"forminator-radiogroup-radio-23-69e074ac78ace-label\" class=\"forminator-label\">TDM <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-23-label-1\" for=\"forminator-field-radio-23-1-69e074ac78ace\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-23\" value=\"one\" id=\"forminator-field-radio-23-1-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-23-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-23-label-2\" for=\"forminator-field-radio-23-2-69e074ac78ace\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-23\" value=\"two\" id=\"forminator-field-radio-23-2-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-23-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"text-24\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-24_69e074ac78ace\" id=\"forminator-field-text-24_69e074ac78ace-label\" class=\"forminator-label\">R\u00e9sultats TDM<\/label><input type=\"text\" name=\"text-24\" value=\"\" placeholder=\"\" id=\"forminator-field-text-24_69e074ac78ace\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-24\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-24-69e074ac78ace-label\"><span id=\"forminator-radiogroup-radio-24-69e074ac78ace-label\" class=\"forminator-label\">IRM <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-24-label-1\" for=\"forminator-field-radio-24-1-69e074ac78ace\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-24\" value=\"one\" id=\"forminator-field-radio-24-1-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-24-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-24-label-2\" for=\"forminator-field-radio-24-2-69e074ac78ace\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-24\" value=\"two\" id=\"forminator-field-radio-24-2-69e074ac78ace\" aria-labelledby=\"forminator-field-radio-24-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"text-31\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-31_69e074ac78ace\" id=\"forminator-field-text-31_69e074ac78ace-label\" class=\"forminator-label\">R\u00e9sultats IRM<\/label><input type=\"text\" name=\"text-31\" value=\"\" placeholder=\"\" id=\"forminator-field-text-31_69e074ac78ace\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-10\" class=\"forminator-field-checkbox forminator-col forminator-col-6 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-10-69e074ac78ace-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-10-69e074ac78ace-label\" class=\"forminator-label\">Type d\u2019AVC<\/span><label id=\"forminator-field-checkbox-10-1-69e074ac78ace-label\" for=\"forminator-field-checkbox-10-1-69e074ac78ace\" class=\"forminator-checkbox\" title=\"AVC isch\u00e9mique\"><input type=\"checkbox\" name=\"checkbox-10[]\" value=\"one\" id=\"forminator-field-checkbox-10-1-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-10-1-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">AVC isch\u00e9mique<\/span><\/label><label id=\"forminator-field-checkbox-10-2-69e074ac78ace-label\" for=\"forminator-field-checkbox-10-2-69e074ac78ace\" class=\"forminator-checkbox\" title=\"AVC H\u00e9morragique\"><input type=\"checkbox\" name=\"checkbox-10[]\" value=\"two\" id=\"forminator-field-checkbox-10-2-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-10-2-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">AVC H\u00e9morragique<\/span><\/label><label id=\"forminator-field-checkbox-10-3-69e074ac78ace-label\" for=\"forminator-field-checkbox-10-3-69e074ac78ace\" class=\"forminator-checkbox\" title=\"H\u00e9morragie intra c\u00e9r\u00e9brale\"><input type=\"checkbox\" name=\"checkbox-10[]\" value=\"H\u00e9morragie-intra-c\u00e9r\u00e9brale\" id=\"forminator-field-checkbox-10-3-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-10-3-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">H\u00e9morragie intra c\u00e9r\u00e9brale<\/span><\/label><label id=\"forminator-field-checkbox-10-4-69e074ac78ace-label\" for=\"forminator-field-checkbox-10-4-69e074ac78ace\" class=\"forminator-checkbox\" title=\"H\u00e9morragie sous arachno\u00efdienne\"><input type=\"checkbox\" name=\"checkbox-10[]\" value=\"H\u00e9morragie-sous-arachno\u00efdienne\" id=\"forminator-field-checkbox-10-4-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-10-4-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">H\u00e9morragie sous arachno\u00efdienne<\/span><\/label><\/div><\/div><div id=\"text-26\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-26_69e074ac78ace\" id=\"forminator-field-text-26_69e074ac78ace-label\" class=\"forminator-label\">Localisation <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-26\" value=\"\" placeholder=\"\" id=\"forminator-field-text-26_69e074ac78ace\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-11\" class=\"forminator-field-checkbox forminator-col forminator-col-6 \"><div role=\"group\" class=\"forminator-field required\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-11-69e074ac78ace-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-11-69e074ac78ace-label\" class=\"forminator-label\">\u00e9tiologies <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-checkbox-11-1-69e074ac78ace-label\" for=\"forminator-field-checkbox-11-1-69e074ac78ace\" class=\"forminator-checkbox\" title=\"HTA\"><input type=\"checkbox\" name=\"checkbox-11[]\" value=\"one\" id=\"forminator-field-checkbox-11-1-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-11-1-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">HTA<\/span><\/label><label id=\"forminator-field-checkbox-11-2-69e074ac78ace-label\" for=\"forminator-field-checkbox-11-2-69e074ac78ace\" class=\"forminator-checkbox\" title=\"FA\"><input type=\"checkbox\" name=\"checkbox-11[]\" value=\"two\" id=\"forminator-field-checkbox-11-2-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-11-2-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">FA<\/span><\/label><label id=\"forminator-field-checkbox-11-3-69e074ac78ace-label\" for=\"forminator-field-checkbox-11-3-69e074ac78ace\" class=\"forminator-checkbox\" title=\"Cause ath\u00e9romateuse\"><input type=\"checkbox\" name=\"checkbox-11[]\" value=\"cause-ath\u00e9romateuse\" id=\"forminator-field-checkbox-11-3-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-11-3-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Cause ath\u00e9romateuse<\/span><\/label><label id=\"forminator-field-checkbox-11-4-69e074ac78ace-label\" for=\"forminator-field-checkbox-11-4-69e074ac78ace\" class=\"forminator-checkbox\" title=\"Thrombose  veineuse c\u00e9r\u00e9brale\"><input type=\"checkbox\" name=\"checkbox-11[]\" value=\"thrombose-veineuse-c\u00e9r\u00e9brale\" id=\"forminator-field-checkbox-11-4-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-11-4-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Thrombose  veineuse c\u00e9r\u00e9brale<\/span><\/label><label id=\"forminator-field-checkbox-11-5-69e074ac78ace-label\" for=\"forminator-field-checkbox-11-5-69e074ac78ace\" class=\"forminator-checkbox\" title=\"Autres cardiopathies:\"><input type=\"checkbox\" name=\"checkbox-11[]\" value=\"autres-cardiopathies:\" id=\"forminator-field-checkbox-11-5-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-11-5-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Autres cardiopathies:<\/span><\/label><\/div><\/div><div id=\"checkbox-12\" class=\"forminator-field-checkbox forminator-col forminator-col-6 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-12-69e074ac78ace-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-12-69e074ac78ace-label\" class=\"forminator-label\">Traitement d\u2019AVC<\/span><label id=\"forminator-field-checkbox-12-1-69e074ac78ace-label\" for=\"forminator-field-checkbox-12-1-69e074ac78ace\" class=\"forminator-checkbox\" title=\"aspirine\"><input type=\"checkbox\" name=\"checkbox-12[]\" value=\"one\" id=\"forminator-field-checkbox-12-1-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-12-1-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">aspirine<\/span><\/label><label id=\"forminator-field-checkbox-12-2-69e074ac78ace-label\" for=\"forminator-field-checkbox-12-2-69e074ac78ace\" class=\"forminator-checkbox\" title=\"clopidogrel\"><input type=\"checkbox\" name=\"checkbox-12[]\" value=\"two\" id=\"forminator-field-checkbox-12-2-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-12-2-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">clopidogrel<\/span><\/label><label id=\"forminator-field-checkbox-12-3-69e074ac78ace-label\" for=\"forminator-field-checkbox-12-3-69e074ac78ace\" class=\"forminator-checkbox\" title=\"statines\"><input type=\"checkbox\" name=\"checkbox-12[]\" value=\"H\u00e9morragie-intra-c\u00e9r\u00e9brale\" id=\"forminator-field-checkbox-12-3-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-12-3-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">statines<\/span><\/label><label id=\"forminator-field-checkbox-12-4-69e074ac78ace-label\" for=\"forminator-field-checkbox-12-4-69e074ac78ace\" class=\"forminator-checkbox\" title=\"anticoagulants : AVK      AOD     h\u00e9parines\"><input type=\"checkbox\" name=\"checkbox-12[]\" value=\"H\u00e9morragie-sous-arachno\u00efdienne\" id=\"forminator-field-checkbox-12-4-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-12-4-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">anticoagulants : AVK      AOD     h\u00e9parines<\/span><\/label><label id=\"forminator-field-checkbox-12-5-69e074ac78ace-label\" for=\"forminator-field-checkbox-12-5-69e074ac78ace\" class=\"forminator-checkbox\" title=\"citicoline (samazina)\"><input type=\"checkbox\" name=\"checkbox-12[]\" value=\"citicoline-(samazina)\" id=\"forminator-field-checkbox-12-5-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-12-5-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">citicoline (samazina)<\/span><\/label><label id=\"forminator-field-checkbox-12-6-69e074ac78ace-label\" for=\"forminator-field-checkbox-12-6-69e074ac78ace\" class=\"forminator-checkbox\" title=\"autres\"><input type=\"checkbox\" name=\"checkbox-12[]\" value=\"autres\" id=\"forminator-field-checkbox-12-6-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-12-6-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">autres<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-13\" class=\"forminator-field-checkbox forminator-col forminator-col-6 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-13-69e074ac78ace-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-13-69e074ac78ace-label\" class=\"forminator-label\">Evolution<\/span><label id=\"forminator-field-checkbox-13-1-69e074ac78ace-label\" for=\"forminator-field-checkbox-13-1-69e074ac78ace\" class=\"forminator-checkbox\" title=\"am\u00e9lioration sans s\u00e9quelles\"><input type=\"checkbox\" name=\"checkbox-13[]\" value=\"one\" id=\"forminator-field-checkbox-13-1-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-13-1-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">am\u00e9lioration sans s\u00e9quelles<\/span><\/label><label id=\"forminator-field-checkbox-13-2-69e074ac78ace-label\" for=\"forminator-field-checkbox-13-2-69e074ac78ace\" class=\"forminator-checkbox\" title=\"am\u00e9lioration avec s\u00e9quelles\"><input type=\"checkbox\" name=\"checkbox-13[]\" value=\"two\" id=\"forminator-field-checkbox-13-2-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-13-2-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">am\u00e9lioration avec s\u00e9quelles<\/span><\/label><label id=\"forminator-field-checkbox-13-3-69e074ac78ace-label\" for=\"forminator-field-checkbox-13-3-69e074ac78ace\" class=\"forminator-checkbox\" title=\"convulsions\"><input type=\"checkbox\" name=\"checkbox-13[]\" value=\"H\u00e9morragie-intra-c\u00e9r\u00e9brale\" id=\"forminator-field-checkbox-13-3-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-13-3-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">convulsions<\/span><\/label><label id=\"forminator-field-checkbox-13-4-69e074ac78ace-label\" for=\"forminator-field-checkbox-13-4-69e074ac78ace\" class=\"forminator-checkbox\" title=\"aggravation de l&#039;\u00e9tat de conscience\"><input type=\"checkbox\" name=\"checkbox-13[]\" value=\"H\u00e9morragie-sous-arachno\u00efdienne\" id=\"forminator-field-checkbox-13-4-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-13-4-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">aggravation de l'\u00e9tat de conscience<\/span><\/label><label id=\"forminator-field-checkbox-13-5-69e074ac78ace-label\" for=\"forminator-field-checkbox-13-5-69e074ac78ace\" class=\"forminator-checkbox\" title=\"d\u00e9c\u00e8s\"><input type=\"checkbox\" name=\"checkbox-13[]\" value=\"citicoline-(samazina)\" id=\"forminator-field-checkbox-13-5-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-13-5-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">d\u00e9c\u00e8s<\/span><\/label><\/div><\/div><div id=\"checkbox-14\" class=\"forminator-field-checkbox forminator-col forminator-col-6 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-14-69e074ac78ace-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-14-69e074ac78ace-label\" class=\"forminator-label\">Orientation pour le suivi :<\/span><label id=\"forminator-field-checkbox-14-1-69e074ac78ace-label\" for=\"forminator-field-checkbox-14-1-69e074ac78ace\" class=\"forminator-checkbox\" title=\"m\u00e9decine interne\"><input type=\"checkbox\" name=\"checkbox-14[]\" value=\"one\" id=\"forminator-field-checkbox-14-1-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-14-1-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">m\u00e9decine interne<\/span><\/label><label id=\"forminator-field-checkbox-14-2-69e074ac78ace-label\" for=\"forminator-field-checkbox-14-2-69e074ac78ace\" class=\"forminator-checkbox\" title=\"cardiologie\"><input type=\"checkbox\" name=\"checkbox-14[]\" value=\"two\" id=\"forminator-field-checkbox-14-2-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-14-2-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">cardiologie<\/span><\/label><label id=\"forminator-field-checkbox-14-3-69e074ac78ace-label\" for=\"forminator-field-checkbox-14-3-69e074ac78ace\" class=\"forminator-checkbox\" title=\"neurologie\"><input type=\"checkbox\" name=\"checkbox-14[]\" value=\"H\u00e9morragie-intra-c\u00e9r\u00e9brale\" id=\"forminator-field-checkbox-14-3-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-14-3-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">neurologie<\/span><\/label><label id=\"forminator-field-checkbox-14-4-69e074ac78ace-label\" for=\"forminator-field-checkbox-14-4-69e074ac78ace\" class=\"forminator-checkbox\" title=\"r\u00e9\u00e9ducation fonctionnelle\"><input type=\"checkbox\" name=\"checkbox-14[]\" value=\"citicoline-(samazina)\" id=\"forminator-field-checkbox-14-4-69e074ac78ace\" aria-labelledby=\"forminator-field-checkbox-14-4-69e074ac78ace-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">r\u00e9\u00e9ducation fonctionnelle<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-28\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-28_69e074ac78ace\" id=\"forminator-field-text-28_69e074ac78ace-label\" class=\"forminator-label\">Dur\u00e9e d\u2019hospitalisation :<\/label><input type=\"text\" name=\"text-28\" value=\"\" placeholder=\"\" id=\"forminator-field-text-28_69e074ac78ace\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Send Message<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"87596d4b3f\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php\/wp-json\/wp\/v2\/pages\/288\" \/><input type=\"hidden\" name=\"form_id\" value=\"287\"><input type=\"hidden\" name=\"page_id\" value=\"288\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/new.samev-dz.com\/index.php\/fiche-avc-mode-dentree-dans-la-maladie\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form><\/div><\/div><\/div><\/div><\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"class_list":["post-288","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v26.8 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Fiche AVC (Mode d\u2019entr\u00e9e dans la maladie) - Soci\u00e9t\u00e9 Alg\u00e9rienne de M\u00e9decine Vasculaire<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, 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