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DHEA (LC/MS)

$45.00

Diagnostic Blood Test:

DHEA, Serum

DHEA is the master sex hormone necessary for libido, energy levels, and immune function. It’s the body’s natural counterbalance to stress hormones like cortisol. Sufficient levels of DHEA are associated with improved cardiovascular health, reduced belly fat, a healthy metabolism, improved mood, enhanced memory, and better sleep. While DHEA-S testing provides information about overall wellness, DHEA tests reflect current stress levels.

SKU: LCP-182 Categories: Diagnostic Labs, Individual Tests, LabCorp

Additional information

Additional information

LabCorp Code	004100

Title

[fusion_form form_post_id="31998"]

<style>.fusion-form-form-wrapper .fusion-form-31998 .fusion-form-tooltip .fusion-form-tooltip-content{color:#ffffff !important;background-color:#333333 !important;border-color:#333333 !important;}.submitThanks{ text-align: center; text: bold; display:none; } .file-up-div{ display:none!important; } .panda-div{ margin: 0 auto; text-align: center; display:none; } .loading-gif{ width: 100px; {</style><div class="fusion-form fusion-form-builder fusion-form-form-wrapper fusion-form-31998" data-form-id="31998" data-config="{"form_id":"31998","form_post_id":"31998","post_id":30754,"form_type":"url","confirmation_type":"message","redirect_url":"","field_labels":{"who_referred_you_to_marek_health":"Who referred you to Marek Health","f_n":"First Name","l_n":"Last Name","email":"Email","pn":"Phone","dob":"Date of Birth","add":"Address","add_2":"","add_city":"","add_state":"","add_zip":"","add_country":"","dl":"Driver License\/State ID #","dl_s":"ID State Issued by","e_c":"Emergency Contact Name","e_p":"Emergency Contact Phone #","gender":"Gender","med_his":"Medical History","mh_og":"Current Medical Issues","pcp":"Primary Care Provider","pcp_p":"Primary Care Phone #","pcp_add":"PCP Address","mh_cpm":"Current Prescription Medications ","mh_otc":"Current over the counter medications?","mh_all":"Do you have allergies?","mh_ps":"Have you had any prior surgeries?","mh_sas":"Do you have issues with Anxiety, Sleep, or Sexual Performance?","fam_his":"Medical history of first degree relatives (mother, father, sisters, brothers)?","adam":"Do you suffer from any of the following conditions? (select all that apply)","m_freq":"Frequency of night urination (times per night)","e_urine":"Are you experiancing difficulty completing urination?","m_lump":"Have you recently noticed any lumps, swelling, tenderness or pain in your testicles?","m_pros":"Results from your last prostate exam (if applicable)","eve":"Do you suffer from any of the following conditions? (select all that apply)","w_hp":"Do you suffer from heavy, irregular or painful periods?","w_if_hp":"Please list symptoms","w_mp":"Date of last menstrual period","w_preg":"Are you currently pregnant or breastfeeding?","w_num_p":"Number of Pregnancies","conceive":"Do you have plans to conceive soon? If no, what are you using for birth control?","w_blad":"Do you suffer from frequent bladder or kidney infections?","w_lump":"Have you recently note any breast lumps, tenderness, pain or nipple discharge?","w_pap":"Date of last pap smear","hh_ex":"Current exercise regimen","hh_diet":"Current diet model?","hh_caf":"Current caffeine intake?","hh_tob":"Tobacco intake?","hh_mj":"Marijuana intake?","hh_drug":"Illegal drug use?","hh_use":"Recreational drug intake? What? How often?","g_i":"What are you interested in?","other":"Other","g_d":"What does your dream outcome working with Marek Health look like?","g_b":"How much per year can you commit towards your dream outcome?","physical":"Physical Exam Documents","labs":"Upload Diagnostic Labwork Results","legal_agree":""},"field_logics":{"who_referred_you_to_marek_health":"","f_n":"","l_n":"","email":"","pn":"","dob":"","add":"","add_2":"","add_city":"","add_state":"","add_zip":"","add_country":"","dl":"","dl_s":"","e_c":"","e_p":"","gender":"[]","med_his":"","mh_og":"","pcp":"","pcp_p":"","pcp_add":"","mh_cpm":"","mh_otc":"","mh_all":"","mh_ps":"","mh_sas":"","fam_his":"","adam":"[{\"operator\":\"and\",\"comparison\":\"equal\",\"field\":\"gender\",\"value\":\"male\"}]","m_freq":"[{\"operator\":\"and\",\"comparison\":\"equal\",\"field\":\"gender\",\"value\":\"male\"}]","e_urine":"[{\"operator\":\"and\",\"comparison\":\"equal\",\"field\":\"gender\",\"value\":\"male\"}]","m_lump":"[{\"operator\":\"and\",\"comparison\":\"equal\",\"field\":\"gender\",\"value\":\"male\"}]","m_pros":"[{\"operator\":\"and\",\"comparison\":\"equal\",\"field\":\"gender\",\"value\":\"male\"}]","eve":"[{\"operator\":\"and\",\"comparison\":\"equal\",\"field\":\"gender\",\"value\":\"female\"}]","w_hp":"[{\"operator\":\"and\",\"comparison\":\"equal\",\"field\":\"gender\",\"value\":\"female\"}]","w_if_hp":"[{\"operator\":\"and\",\"comparison\":\"equal\",\"field\":\"gender\",\"value\":\"female\"},{\"operator\":\"and\",\"comparison\":\"equal\",\"field\":\"w_hp\",\"value\":\"YES\"}]","w_mp":"[{\"operator\":\"and\",\"comparison\":\"equal\",\"field\":\"gender\",\"value\":\"female\"}]","w_preg":"[{\"operator\":\"and\",\"comparison\":\"equal\",\"field\":\"gender\",\"value\":\"female\"}]","w_num_p":"[{\"operator\":\"and\",\"comparison\":\"equal\",\"field\":\"gender\",\"value\":\"female\"}]","conceive":"[{\"operator\":\"and\",\"comparison\":\"equal\",\"field\":\"gender\",\"value\":\"female\"}]","w_blad":"[{\"operator\":\"and\",\"comparison\":\"equal\",\"field\":\"gender\",\"value\":\"femlae\"}]","w_lump":"[{\"operator\":\"and\",\"comparison\":\"equal\",\"field\":\"gender\",\"value\":\"female\"}]","w_pap":"[{\"operator\":\"and\",\"comparison\":\"equal\",\"field\":\"gender\",\"value\":\"female\"}]","hh_ex":"","hh_diet":"","hh_caf":"","hh_tob":"","hh_mj":"","hh_drug":"","hh_use":"[{\"operator\":\"and\",\"comparison\":\"equal\",\"field\":\"hh_drug\",\"value\":\"YES\"}]","g_i":"","other":"","g_d":"","g_b":"","physical":"","labs":"","legal_agree":""}}"><form action="localhost" method="post" class="fusion-form fusion-form-post fusion-form-31998" enctype="multipart/form-data"><div class="fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling" style="background-color: #070707;background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#eae9e9;border-style:solid;" id="hhqForm" ><div class="fusion-builder-row fusion-row fusion-flex-align-items-flex-start" style="max-width:1248px;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"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#070707;padding: 0px 0px 0px 0px;"><div class="fusion-text fusion-text-1 fusion-text-no-margin" style="text-align:center;"><h4 style="font-family: Montserrat; font-weight: 400; font-size: 24px;" data-fusion-font="true" data-fusion-google-font="Montserrat" data-fusion-google-variant="400">HEALTH HISTORY QUESTIONNAIRE</h4> </div><div class="fusion-text fusion-text-2" style="text-align:center;margin-right:20%;margin-left:20%;"><h3 style="font-family: Montserrat; font-weight: 400; font-size: 16px;" data-fusion-font="true" data-fusion-google-font="Montserrat" data-fusion-google-variant="400"><span style="font-weight: 400; font-family: Montserrat; line-height: 16px;" data-fusion-font="true" data-fusion-google-font="Montserrat" data-fusion-google-variant="400">For starters, congratulations—we’re excited to see you’ve taken an interest in creating a better living for yourself through science.</span></h3> <p><span style="font-weight: 400; font-family: Montserrat; line-height: 16px;" data-fusion-font="true" data-fusion-google-font="Montserrat" data-fusion-google-variant="400">I know you are just as excited as we are to get started however Marek is only able to take on a limited amount of patients per year. </span><span style="font-weight: 400;"><span style="font-family: Montserrat; font-weight: 400; line-height: 16px;" data-fusion-font="true" data-fusion-google-font="Montserrat" data-fusion-google-variant="400">Please complete this health history questionnaire to make sure you qualify to join. If you are successful you will be redirected to our booking system to schedule your intake evaluation.</span> </span></p> </div><div class="fusion-text fusion-text-3"><h3 style="font-family: Roboto; font-weight: 400; font-size: 20px;" data-fusion-font="true" data-fusion-google-font="Roboto" data-fusion-google-variant="400">Demographics</h3> </div></div><style type="text/css">.fusion-body .fusion-builder-column-0{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-0 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-0{width:100% !important;order : 0;}.fusion-builder-column-0 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-0{width:100% !important;order : 0;}.fusion-builder-column-0 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-select-field fusion-form-label-above" data-form-id="31998"><label for="who_referred_you_to_marek_health">Who referred you to Marek Health</label><div class="fusion-select-wrapper"><select tabindex="" id="who_referred_you_to_marek_health" name="who_referred_you_to_marek_health" class="fusion-form-input" data-holds-private-data="false"><option value="" disabled selected>Select an option</option><option value="Derek from MPMD" >Derek from MPMD</option><option value="Stan Efferding" >Stan Efferding</option><option value="PowerProject" >PowerProject</option><option value="Another patient" >Another patient</option><option value="Other" >Other</option></select><div class="select-arrow"><svg width="12" height="8" viewBox="0 0 12 8" fill="none" xmlns="http://www.w3.org/2000/svg"> <path d="M1.5 1.75L6 6.25L10.5 1.75" stroke="#6D6D6D" stroke-width="2" stroke-linecap="round" stroke-linejoin="round"/> </svg></div></div></div></div><style type="text/css">.fusion-body .fusion-builder-column-1{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-1 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-1{width:100% !important;order : 0;}.fusion-builder-column-1 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-1{width:100% !important;order : 0;}.fusion-builder-column-1 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-text fusion-text-4"><h3 style="font-family: Roboto; font-weight: 400; font-size: 20px;" data-fusion-font="true" data-fusion-google-font="Roboto" data-fusion-google-variant="400">Patient Information</h3> </div></div><style type="text/css">.fusion-body .fusion-builder-column-2{width:100% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-2 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-2{width:100% !important;order : 0;}.fusion-builder-column-2 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-2{width:100% !important;order : 0;}.fusion-builder-column-2 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-3 fusion_builder_column_1_2 1_2 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-text-field fusion-form-label-above" data-form-id="31998"><div class="fusion-form-label-wrapper"><label for="f_n">First Name <abbr class="fusion-form-element-required" title="required">*</abbr></label></div><input type="text" name="f_n" id="f_n" value="" class="fusion-form-input" required="true" aria-required="true" placeholder="as it appears on your ID*" data-holds-private-data="false" minlength="0"/></div></div><style type="text/css">.fusion-body .fusion-builder-column-3{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-3 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only 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for="l_n">Last Name <abbr class="fusion-form-element-required" title="required">*</abbr></label></div><input type="text" name="l_n" id="l_n" value="" class="fusion-form-input" required="true" aria-required="true" placeholder="as it appears on your ID*" data-holds-private-data="false" minlength="0"/></div></div><style type="text/css">.fusion-body .fusion-builder-column-4{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-4 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-4{width:50% !important;order : 0;}.fusion-builder-column-4 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-4{width:100% !important;order : 0;}.fusion-builder-column-4 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-5 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-email-field fusion-form-label-above" data-form-id="31998"><div class="fusion-form-label-wrapper"><label for="email">Email</label></div><input type="email" name="email" id="email" value="" class="fusion-form-input" placeholder="Email" data-holds-private-data="false"/></div></div><style type="text/css">.fusion-body .fusion-builder-column-5{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-5 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-5{width:100% !important;order : 0;}.fusion-builder-column-5 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-5{width:100% !important;order : 0;}.fusion-builder-column-5 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-6 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left 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(max-width:1024px) {.fusion-body .fusion-builder-column-6{width:100% !important;order : 0;}.fusion-builder-column-6 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-6{width:100% !important;order : 0;}.fusion-builder-column-6 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-7 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div id="#dob" class="fusion-form-field fusion-form-date-field fusion-form-label-above #dob" data-form-id="31998"><label for="dob">Date of Birth</label><div 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: 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-7{width:100% !important;order : 0;}.fusion-builder-column-7 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-8 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-text-field fusion-form-label-above" data-form-id="31998"><div class="fusion-form-label-wrapper"><label for="add">Address</label></div><input type="text" name="add" id="add" value="" class="fusion-form-input" placeholder="Street Address" data-holds-private-data="false" minlength="0"/></div><div class="fusion-form-field fusion-form-text-field fusion-form-label-above" data-form-id="31998"><input type="text" name="add_2" id="add_2" value="" class="fusion-form-input" placeholder="Address Line 2" data-holds-private-data="false" minlength="0"/></div></div><style type="text/css">.fusion-body .fusion-builder-column-8{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-8 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-8{width:100% !important;order : 0;}.fusion-builder-column-8 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-8{width:100% !important;order : 0;}.fusion-builder-column-8 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-9 fusion_builder_column_1_2 1_2 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-text-field fusion-form-label-above" data-form-id="31998"><input type="text" name="add_city" id="add_city" value="" class="fusion-form-input" placeholder="City" data-holds-private-data="false" minlength="0"/></div></div><style type="text/css">.fusion-body .fusion-builder-column-9{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-9 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-9{width:50% !important;order : 0;}.fusion-builder-column-9 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-9{width:100% !important;order : 0;}.fusion-builder-column-9 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-10 fusion_builder_column_1_2 1_2 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-select-field fusion-form-label-above" data-form-id="31998"><div class="fusion-select-wrapper"><select tabindex="" id="add_state" name="add_state" class="fusion-form-input" data-holds-private-data="false"><option value="Alabama" >Alabama</option><option value="Alaska" >Alaska</option><option value="Arizona" >Arizona</option><option value="Arkansas" >Arkansas</option><option value="California" >California</option><option value="Colorado" >Colorado</option><option value="Connecticut" >Connecticut</option><option value="Delaware" >Delaware</option><option value="District Of Columbia" >District Of Columbia</option><option value="Florida" >Florida</option><option value="Georgia" >Georgia</option><option value="Hawaii" >Hawaii</option><option value="Idaho" >Idaho</option><option value="Illinois" >Illinois</option><option value="Indiana" >Indiana</option><option value="Iowa" >Iowa</option><option value="Kansas" >Kansas</option><option value="Kentucky" >Kentucky</option><option value="Louisiana" >Louisiana</option><option value="Maine" >Maine</option><option value="Maryland" >Maryland</option><option value="Massachusetts" >Massachusetts</option><option value="Michigan" >Michigan</option><option value="Minnesota" >Minnesota</option><option value="Mississippi" >Mississippi</option><option value="Missouri" >Missouri</option><option value="Montana" >Montana</option><option value="Nebraska" >Nebraska</option><option value="Nevada" >Nevada</option><option value="New Hampshire" >New Hampshire</option><option value="New Jersey" >New Jersey</option><option value="New Mexico" >New Mexico</option><option value="New York" >New York</option><option value="North Carolina" >North Carolina</option><option value="North Dakota" >North Dakota</option><option value="Ohio" >Ohio</option><option value="Oklahoma" >Oklahoma</option><option value="Oregon" >Oregon</option><option value="Pennsylvania" >Pennsylvania</option><option value="Rhode Island" >Rhode Island</option><option value="South Carolina" >South Carolina</option><option value="South Dakota" >South Dakota</option><option value="Tennessee" >Tennessee</option><option value="Texas" >Texas</option><option value="Utah" >Utah</option><option value="Vermont" >Vermont</option><option value="Virginia" >Virginia</option><option value="Washington" >Washington</option><option value="West Virginia" >West Virginia</option><option value="Wisconsin" >Wisconsin</option><option value="Wyoming" >Wyoming</option><option value="Armed Forces (AA)" >Armed Forces (AA)</option><option value="Armed Forces (AE)" >Armed Forces (AE)</option><option value="Armed Forces (AP)" >Armed Forces (AP)</option></select><div class="select-arrow"><svg width="12" height="8" viewBox="0 0 12 8" fill="none" xmlns="http://www.w3.org/2000/svg"> <path d="M1.5 1.75L6 6.25L10.5 1.75" stroke="#6D6D6D" stroke-width="2" stroke-linecap="round" stroke-linejoin="round"/> </svg></div></div></div></div><style type="text/css">.fusion-body .fusion-builder-column-10{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-10 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-10{width:50% !important;order : 0;}.fusion-builder-column-10 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-10{width:100% !important;order : 0;}.fusion-builder-column-10 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-11 fusion_builder_column_1_2 1_2 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-text-field fusion-form-label-above" data-form-id="31998"><input type="text" name="add_zip" id="add_zip" value="" class="fusion-form-input" placeholder="Postal / Zip Code" data-holds-private-data="false" minlength="0"/></div></div><style type="text/css">.fusion-body .fusion-builder-column-11{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-11 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-11{width:50% !important;order : 0;}.fusion-builder-column-11 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-11{width:100% !important;order : 0;}.fusion-builder-column-11 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-12 fusion_builder_column_1_2 1_2 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div id="country" class="fusion-form-field fusion-form-select-field fusion-form-label-above country" data-form-id="31998"><div class="fusion-select-wrapper"><select tabindex="" id="add_country" name="add_country" class="fusion-form-input" required="true" aria-required="true" data-holds-private-data="false"><option value="" disabled selected>Country</option><option value="Afghanistan" >Afghanistan</option><option value="Åland Islands" >Åland Islands</option><option value="Albania" >Albania</option><option value="Algeria" >Algeria</option><option value="American Samoa" >American Samoa</option><option value="Andorra" >Andorra</option><option value="Angola" >Angola</option><option value="Anguilla" >Anguilla</option><option value="Antarctica" >Antarctica</option><option value="Antigua and Barbuda" >Antigua and Barbuda</option><option value="Argentina" >Argentina</option><option value="Armenia" >Armenia</option><option value="Aruba" >Aruba</option><option value="Australia" >Australia</option><option value="Austria" >Austria</option><option value="Azerbaijan" >Azerbaijan</option><option value="Bahamas" >Bahamas</option><option value="Bahrain" >Bahrain</option><option value="Bangladesh" >Bangladesh</option><option value="Barbados" >Barbados</option><option value="Belarus" >Belarus</option><option value="Belgium" >Belgium</option><option value="Belize" >Belize</option><option value="Benin" >Benin</option><option value="Bermuda" >Bermuda</option><option value="Bhutan" >Bhutan</option><option value="Bolivia" >Bolivia</option><option value="Bonaire, Sint Eustatius and Saba" >Bonaire, Sint Eustatius and Saba</option><option value="Bosnia and Herzegovina" >Bosnia and Herzegovina</option><option value="Botswana" >Botswana</option><option value="Bouvet Island" >Bouvet Island</option><option value="Brazil" >Brazil</option><option value="British Indian Ocean Territory" >British Indian Ocean Territory</option><option value="Brunei Darussalam" >Brunei Darussalam</option><option value="Bulgaria" >Bulgaria</option><option value="Burkina Faso" >Burkina Faso</option><option value="Burundi" >Burundi</option><option value="Cambodia" >Cambodia</option><option value="Cameroon" >Cameroon</option><option value="Canada" >Canada</option><option value="Cape Verde" >Cape Verde</option><option value="Cayman Islands" >Cayman Islands</option><option value="Central African Republic" >Central African Republic</option><option value="Chad" >Chad</option><option value="Chile" >Chile</option><option value="China" >China</option><option value="Christmas Island" >Christmas Island</option><option value="Cocos Islands" >Cocos Islands</option><option value="Colombia" >Colombia</option><option value="Comoros" >Comoros</option><option value="Congo, Democratic Republic of the" >Congo, Democratic Republic of the</option><option value="Congo, Republic of the" >Congo, Republic of the</option><option value="Cook Islands" >Cook Islands</option><option value="Costa Rica" >Costa Rica</option><option value="Côte d'Ivoire" >Côte d'Ivoire</option><option value="Croatia" >Croatia</option><option value="Cuba" >Cuba</option><option value="Curaçao" >Curaçao</option><option value="Cyprus" >Cyprus</option><option value="Czech Republic" >Czech Republic</option><option value="Denmark" >Denmark</option><option value="Djibouti" >Djibouti</option><option value="Dominica" >Dominica</option><option value="Dominican Republic" >Dominican Republic</option><option value="Ecuador" >Ecuador</option><option value="Egypt" >Egypt</option><option value="El Salvador" >El Salvador</option><option value="Equatorial Guinea" >Equatorial Guinea</option><option value="Eritrea" >Eritrea</option><option value="Estonia" >Estonia</option><option value="Eswatini (Swaziland)" >Eswatini (Swaziland)</option><option value="Ethiopia" >Ethiopia</option><option value="Falkland Islands" >Falkland Islands</option><option value="Faroe Islands" >Faroe Islands</option><option value="Fiji" >Fiji</option><option value="Finland" >Finland</option><option value="France" >France</option><option value="French Guiana" >French Guiana</option><option value="French Polynesia" >French Polynesia</option><option value="French Southern Territories" >French Southern Territories</option><option value="Gabon" >Gabon</option><option value="Gambia" >Gambia</option><option value="Georgia" >Georgia</option><option value="Germany" >Germany</option><option value="Ghana" >Ghana</option><option value="Gibraltar" >Gibraltar</option><option value="Greece" >Greece</option><option value="Greenland" >Greenland</option><option value="Grenada" >Grenada</option><option value="Guadeloupe" >Guadeloupe</option><option value="Guam" >Guam</option><option value="Guatemala" >Guatemala</option><option value="Guernsey" >Guernsey</option><option value="Guinea" >Guinea</option><option value="Guinea-Bissau" >Guinea-Bissau</option><option value="Guyana" >Guyana</option><option value="Haiti" >Haiti</option><option value="Heard and McDonald Islands" >Heard and McDonald Islands</option><option value="Holy See" >Holy See</option><option value="Honduras" >Honduras</option><option value="Hong Kong" >Hong Kong</option><option value="Hungary" >Hungary</option><option value="Iceland" >Iceland</option><option value="India" >India</option><option value="Indonesia" >Indonesia</option><option value="Iran" >Iran</option><option value="Iraq" >Iraq</option><option value="Ireland" >Ireland</option><option value="Isle of Man" >Isle of Man</option><option value="Israel" >Israel</option><option value="Italy" >Italy</option><option value="Jamaica" >Jamaica</option><option value="Japan" >Japan</option><option value="Jersey" >Jersey</option><option value="Jordan" >Jordan</option><option value="Kazakhstan" >Kazakhstan</option><option value="Kenya" >Kenya</option><option value="Kiribati" >Kiribati</option><option value="Kuwait" >Kuwait</option><option value="Kyrgyzstan" >Kyrgyzstan</option><option value="Lao People's Democratic Republic" >Lao People's Democratic Republic</option><option value="Latvia" >Latvia</option><option value="Lebanon" >Lebanon</option><option value="Lesotho" >Lesotho</option><option value="Liberia" >Liberia</option><option value="Libya" >Libya</option><option value="Liechtenstein" >Liechtenstein</option><option value="Lithuania" >Lithuania</option><option value="Luxembourg" >Luxembourg</option><option value="Macau" >Macau</option><option value="Macedonia" >Macedonia</option><option value="Madagascar" >Madagascar</option><option value="Malawi" >Malawi</option><option value="Malaysia" >Malaysia</option><option value="Maldives" >Maldives</option><option value="Mali" >Mali</option><option value="Malta" >Malta</option><option value="Marshall Islands" >Marshall Islands</option><option value="Martinique" >Martinique</option><option value="Mauritania" >Mauritania</option><option value="Mauritius" >Mauritius</option><option value="Mayotte" >Mayotte</option><option value="Mexico" >Mexico</option><option value="Micronesia" >Micronesia</option><option value="Moldova" >Moldova</option><option value="Monaco" >Monaco</option><option value="Mongolia" >Mongolia</option><option value="Montenegro" >Montenegro</option><option value="Montserrat" >Montserrat</option><option value="Morocco" >Morocco</option><option value="Mozambique" >Mozambique</option><option value="Myanmar" >Myanmar</option><option value="Namibia" >Namibia</option><option value="Nauru" >Nauru</option><option value="Nepal" >Nepal</option><option value="Netherlands" >Netherlands</option><option value="New Caledonia" >New Caledonia</option><option value="New Zealand" >New Zealand</option><option value="Nicaragua" >Nicaragua</option><option value="Niger" >Niger</option><option value="Nigeria" >Nigeria</option><option value="Niue" >Niue</option><option value="Norfolk Island" >Norfolk Island</option><option value="North Korea" >North Korea</option><option value="Northern Mariana Islands" >Northern Mariana Islands</option><option value="Norway" >Norway</option><option value="Oman" >Oman</option><option value="Pakistan" >Pakistan</option><option value="Palau" >Palau</option><option value="Palestine, State of" >Palestine, State of</option><option value="Panama" >Panama</option><option value="Papua New Guinea" >Papua New Guinea</option><option value="Paraguay" >Paraguay</option><option value="Peru" >Peru</option><option value="Philippines" >Philippines</option><option value="Pitcairn" >Pitcairn</option><option value="Poland" >Poland</option><option value="Portugal" >Portugal</option><option value="Puerto Rico" >Puerto Rico</option><option value="Qatar" >Qatar</option><option value="Réunion" >Réunion</option><option value="Romania" >Romania</option><option value="Russia" >Russia</option><option value="Rwanda" >Rwanda</option><option value="Saint Barthélemy" >Saint Barthélemy</option><option value="Saint Helena" >Saint Helena</option><option value="Saint Kitts and Nevis" >Saint Kitts and Nevis</option><option value="Saint Lucia" >Saint Lucia</option><option value="Saint Martin" >Saint Martin</option><option value="Saint Pierre and Miquelon" >Saint Pierre and Miquelon</option><option value="Saint Vincent and the Grenadines" >Saint Vincent and the Grenadines</option><option value="Samoa" >Samoa</option><option value="San Marino" >San Marino</option><option value="Sao Tome and Principe" >Sao Tome and Principe</option><option value="Saudi Arabia" >Saudi Arabia</option><option value="Senegal" >Senegal</option><option value="Serbia" >Serbia</option><option value="Seychelles" >Seychelles</option><option value="Sierra Leone" >Sierra Leone</option><option value="Singapore" >Singapore</option><option value="Sint Maarten" >Sint Maarten</option><option value="Slovakia" >Slovakia</option><option value="Slovenia" >Slovenia</option><option value="Solomon Islands" >Solomon Islands</option><option value="Somalia" >Somalia</option><option value="South Africa" >South Africa</option><option value="South Georgia" >South Georgia</option><option value="South Korea" >South Korea</option><option value="South Sudan" >South Sudan</option><option value="Spain" >Spain</option><option value="Sri Lanka" >Sri Lanka</option><option value="Sudan" >Sudan</option><option value="Suriname" >Suriname</option><option value="Svalbard and Jan Mayen Islands" >Svalbard and Jan Mayen Islands</option><option value="Sweden" >Sweden</option><option value="Switzerland" >Switzerland</option><option value="Syria" >Syria</option><option value="Taiwan" >Taiwan</option><option value="Tajikistan" >Tajikistan</option><option value="Tanzania" >Tanzania</option><option value="Thailand" >Thailand</option><option value="Timor-Leste" >Timor-Leste</option><option value="Togo" >Togo</option><option value="Tokelau" >Tokelau</option><option value="Tonga" >Tonga</option><option value="Trinidad and Tobago" >Trinidad and Tobago</option><option value="Tunisia" >Tunisia</option><option value="Turkey" >Turkey</option><option value="Turkmenistan" >Turkmenistan</option><option value="Turks and Caicos Islands" >Turks and Caicos Islands</option><option value="Tuvalu" >Tuvalu</option><option value="Uganda" >Uganda</option><option value="Ukraine" >Ukraine</option><option value="United Arab Emirates" >United Arab Emirates</option><option value="United Kingdom" >United Kingdom</option><option value="United States" selected >United States</option><option value="Uruguay" >Uruguay</option><option value="US Minor Outlying Islands" >US Minor Outlying Islands</option><option value="Uzbekistan" >Uzbekistan</option><option value="Vanuatu" >Vanuatu</option><option value="Venezuela" >Venezuela</option><option value="Vietnam" >Vietnam</option><option value="Virgin Islands, British" >Virgin Islands, British</option><option value="Virgin Islands, U.S." >Virgin Islands, U.S.</option><option value="Wallis and Futuna" >Wallis and Futuna</option><option value="Western Sahara" >Western Sahara</option><option value="Yemen" >Yemen</option><option value="Zambia" >Zambia</option><option value="Zimbabwe" >Zimbabwe</option></select><div class="select-arrow"><svg width="12" height="8" viewBox="0 0 12 8" fill="none" xmlns="http://www.w3.org/2000/svg"> <path d="M1.5 1.75L6 6.25L10.5 1.75" stroke="#6D6D6D" stroke-width="2" stroke-linecap="round" stroke-linejoin="round"/> </svg></div></div></div></div><style type="text/css">.fusion-body .fusion-builder-column-12{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-12 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-12{width:50% !important;order : 0;}.fusion-builder-column-12 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-12{width:100% !important;order : 0;}.fusion-builder-column-12 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-13 fusion_builder_column_1_2 1_2 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-text-field fusion-form-label-above" data-form-id="31998"><div class="fusion-form-label-wrapper"><label for="dl">Driver License/State ID #</label></div><input type="text" name="dl" id="dl" value="" class="fusion-form-input" placeholder="Required for order fulfillment" data-holds-private-data="false" minlength="0"/></div></div><style type="text/css">.fusion-body .fusion-builder-column-13{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-13 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-13{width:50% !important;order : 0;}.fusion-builder-column-13 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-13{width:100% !important;order : 0;}.fusion-builder-column-13 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-14 fusion_builder_column_1_2 1_2 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-select-field fusion-form-label-above" data-form-id="31998"><label for="dl_s">ID State Issued by</label><div class="fusion-select-wrapper"><select tabindex="" id="dl_s" name="dl_s" class="fusion-form-input" data-holds-private-data="false"><option value="Alabama" >Alabama</option><option value="Alaska" >Alaska</option><option value="Arizona" >Arizona</option><option value="Arkansas" >Arkansas</option><option value="California" >California</option><option value="Colorado" >Colorado</option><option value="Connecticut" >Connecticut</option><option value="Delaware" >Delaware</option><option value="District Of Columbia" >District Of Columbia</option><option value="Florida" >Florida</option><option value="Georgia" >Georgia</option><option value="Hawaii" >Hawaii</option><option value="Idaho" >Idaho</option><option value="Illinois" >Illinois</option><option value="Indiana" >Indiana</option><option value="Iowa" >Iowa</option><option value="Kansas" >Kansas</option><option value="Kentucky" >Kentucky</option><option value="Louisiana" >Louisiana</option><option value="Maine" >Maine</option><option value="Maryland" >Maryland</option><option value="Massachusetts" >Massachusetts</option><option value="Michigan" >Michigan</option><option value="Minnesota" >Minnesota</option><option value="Mississippi" >Mississippi</option><option value="Missouri" >Missouri</option><option value="Montana" >Montana</option><option value="Nebraska" >Nebraska</option><option value="Nevada" >Nevada</option><option value="New Hampshire" >New Hampshire</option><option value="New Jersey" >New Jersey</option><option value="New Mexico" >New Mexico</option><option value="New York" >New York</option><option value="North Carolina" >North Carolina</option><option value="North Dakota" >North Dakota</option><option value="Ohio" >Ohio</option><option value="Oklahoma" >Oklahoma</option><option value="Oregon" >Oregon</option><option value="Pennsylvania" >Pennsylvania</option><option value="Rhode Island" >Rhode Island</option><option value="South Carolina" >South Carolina</option><option value="South Dakota" >South Dakota</option><option value="Tennessee" >Tennessee</option><option value="Texas" >Texas</option><option value="Utah" >Utah</option><option value="Vermont" >Vermont</option><option value="Virginia" >Virginia</option><option value="Washington" >Washington</option><option value="West Virginia" >West Virginia</option><option value="Wisconsin" >Wisconsin</option><option value="Wyoming" >Wyoming</option><option value="Armed Forces (AA)" >Armed Forces (AA)</option><option value="Armed Forces (AE)" >Armed Forces (AE)</option><option value="Armed Forces (AP)" >Armed Forces (AP)</option></select><div class="select-arrow"><svg width="12" height="8" viewBox="0 0 12 8" fill="none" xmlns="http://www.w3.org/2000/svg"> <path d="M1.5 1.75L6 6.25L10.5 1.75" stroke="#6D6D6D" stroke-width="2" stroke-linecap="round" stroke-linejoin="round"/> </svg></div></div></div></div><style type="text/css">.fusion-body .fusion-builder-column-14{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-14 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-14{width:50% !important;order : 0;}.fusion-builder-column-14 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-14{width:100% !important;order : 0;}.fusion-builder-column-14 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-15 fusion_builder_column_1_2 1_2 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-text-field fusion-form-label-above" data-form-id="31998"><div class="fusion-form-label-wrapper"><label for="e_c">Emergency Contact Name</label></div><input type="text" name="e_c" id="e_c" value="" class="fusion-form-input" placeholder="First and Last" data-holds-private-data="false" minlength="0"/></div></div><style type="text/css">.fusion-body .fusion-builder-column-15{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-15 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-15{width:50% !important;order : 0;}.fusion-builder-column-15 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-15{width:100% !important;order : 0;}.fusion-builder-column-15 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-16 fusion_builder_column_1_2 1_2 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-phone-number-field fusion-form-label-above" data-form-id="31998"><div class="fusion-form-label-wrapper"><label for="e_p">Emergency Contact Phone #</label></div><div class="fusion-form-input-with-icon"><i class="fa-phone-square-alt fas"></i><input type="phone-number" name="e_p" id="e_p" value="" class="fusion-form-input" data-holds-private-data="false" pattern="[0-9()#&+*-=.]+" title="Only numbers and phone characters are accepted."/></div></div></div><style type="text/css">.fusion-body .fusion-builder-column-16{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-16 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-16{width:50% !important;order : 0;}.fusion-builder-column-16 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-16{width:100% !important;order : 0;}.fusion-builder-column-16 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-17 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-select-field fusion-form-label-above" data-form-id="31998"><label for="gender">Gender</label><div class="fusion-select-wrapper"><select tabindex="" id="gender" name="gender" class="fusion-form-input" data-holds-private-data="false"><option value="select one" selected >select one</option><option value="male" >Male</option><option value="female" >Female</option></select><div class="select-arrow"><svg width="12" height="8" viewBox="0 0 12 8" fill="none" xmlns="http://www.w3.org/2000/svg"> <path d="M1.5 1.75L6 6.25L10.5 1.75" stroke="#6D6D6D" stroke-width="2" stroke-linecap="round" stroke-linejoin="round"/> </svg></div></div></div></div><style type="text/css">.fusion-body .fusion-builder-column-17{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-17 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-17{width:100% !important;order : 0;}.fusion-builder-column-17 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-17{width:100% !important;order : 0;}.fusion-builder-column-17 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-18 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#070707;padding: 0px 0px 0px 0px;"><div class="fusion-text fusion-text-5"><h3 style="font-family: Montserrat; font-weight: 400; font-size: 20px;" data-fusion-font="true" data-fusion-google-font="Montserrat" data-fusion-google-variant="400">Personal Health History</h3> </div></div><style type="text/css">.fusion-body .fusion-builder-column-18{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-18 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-18{width:100% !important;order : 0;}.fusion-builder-column-18 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-18{width:100% !important;order : 0;}.fusion-builder-column-18 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-19 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above" data-form-id="31998"><label for="med_his">Medical History</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="med_his" name="med_his" class="fusion-form-input" data-holds-private-data="false"></textarea></div><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above" data-form-id="31998"><label for="mh_og">Current Medical Issues</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="mh_og" name="mh_og" class="fusion-form-input" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-19{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-19 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-19{width:100% !important;order : 0;}.fusion-builder-column-19 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-19{width:100% !important;order : 0;}.fusion-builder-column-19 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-20 fusion_builder_column_1_2 1_2 fusion-flex-column fusion-flex-align-self-stretch"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-end fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-text-field fusion-form-label-above" data-form-id="31998"><div class="fusion-form-label-wrapper"><label for="pcp">Primary Care Provider</label></div><input type="text" name="pcp" id="pcp" value="" class="fusion-form-input" placeholder="First Last" data-holds-private-data="false" minlength="0"/></div></div><style type="text/css">.fusion-body .fusion-builder-column-20{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-20 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-20{width:50% !important;order : 0;}.fusion-builder-column-20 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-20{width:100% !important;order : 0;}.fusion-builder-column-20 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-21 fusion_builder_column_1_2 1_2 fusion-flex-column fusion-flex-align-self-stretch"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-end fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-phone-number-field fusion-form-label-above" data-form-id="31998"><div class="fusion-form-label-wrapper"><label for="pcp_p">Primary Care Phone #</label></div><div class="fusion-form-input-with-icon"><i class="fa-phone-square-alt fas"></i><input type="phone-number" name="pcp_p" id="pcp_p" value="" class="fusion-form-input" data-holds-private-data="false" pattern="[0-9()#&+*-=.]+" title="Only numbers and phone characters are accepted."/></div></div></div><style type="text/css">.fusion-body .fusion-builder-column-21{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-21 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-21{width:50% !important;order : 0;}.fusion-builder-column-21 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-21{width:100% !important;order : 0;}.fusion-builder-column-21 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-22 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above" data-form-id="31998"><label for="pcp_add">PCP Address</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="pcp_add" name="pcp_add" class="fusion-form-input" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-22{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-22 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-22{width:100% !important;order : 0;}.fusion-builder-column-22 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-22{width:100% !important;order : 0;}.fusion-builder-column-22 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-23 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above" data-form-id="31998"><label for="mh_cpm">Current Prescription Medications </label><textarea cols="40" minlength="0" rows="4" tabindex="" id="mh_cpm" name="mh_cpm" class="fusion-form-input" placeholder="List them here" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-23{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-23 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-23{width:100% !important;order : 0;}.fusion-builder-column-23 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-23{width:100% !important;order : 0;}.fusion-builder-column-23 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-24 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above" data-form-id="31998"><label for="mh_otc">Current over the counter medications?</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="mh_otc" name="mh_otc" class="fusion-form-input" placeholder="List them here" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-24{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-24 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-24{width:100% !important;order : 0;}.fusion-builder-column-24 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-24{width:100% !important;order : 0;}.fusion-builder-column-24 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-25 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above" data-form-id="31998"><label for="mh_all">Do you have allergies?</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="mh_all" name="mh_all" class="fusion-form-input" placeholder="List them here" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-25{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-25 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-25{width:100% !important;order : 0;}.fusion-builder-column-25 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-25{width:100% !important;order : 0;}.fusion-builder-column-25 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-26 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above" data-form-id="31998"><label for="mh_ps">Have you had any prior surgeries?</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="mh_ps" name="mh_ps" class="fusion-form-input" placeholder="List them here" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-26{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-26 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-26{width:100% !important;order : 0;}.fusion-builder-column-26 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-26{width:100% !important;order : 0;}.fusion-builder-column-26 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-27 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-checkbox-field fusion-form-label-above" data-form-id="31998"><div class="fusion-form-label-wrapper"><span class="label">Do you have issues with Anxiety, Sleep, or Sexual Performance?</span></div><fieldset><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-mh_sas-1-0" type="checkbox" value="Anxiety" name="mh_sas[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-mh_sas-1-0">Anxiety</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-mh_sas-1-1" type="checkbox" value="Sleeping Difficulties" name="mh_sas[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-mh_sas-1-1">Sleeping Difficulties</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-mh_sas-1-2" type="checkbox" value="Sexual Difficulties" name="mh_sas[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-mh_sas-1-2">Sexual Difficulties</label></div></fieldset></div></div><style type="text/css">.fusion-body .fusion-builder-column-27{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-27 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-27{width:100% !important;order : 0;}.fusion-builder-column-27 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-27{width:100% !important;order : 0;}.fusion-builder-column-27 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-28 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above" data-form-id="31998"><label for="fam_his">Medical history of first degree relatives (mother, father, sisters, brothers)?</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="fam_his" name="fam_his" class="fusion-form-input" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-28{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-28 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-28{width:100% !important;order : 0;}.fusion-builder-column-28 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-28{width:100% !important;order : 0;}.fusion-builder-column-28 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-29 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-checkbox-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><div class="fusion-form-label-wrapper"><span class="label">Do you suffer from any of the following conditions? (select all that apply)</span></div><fieldset><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-adam-2-0" type="checkbox" value="YES" name="adam[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-adam-2-0">Decrease in Libido (sex drive)</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-adam-2-1" type="checkbox" value="YES" name="adam[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-adam-2-1">Lack of Energy</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-adam-2-2" type="checkbox" value="YES" name="adam[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-adam-2-2">Decrease in Strength and/or Endurance</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-adam-2-3" type="checkbox" value="YES" name="adam[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-adam-2-3">Lost Height</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-adam-2-4" type="checkbox" value="YES" name="adam[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-adam-2-4">Sad and/or Grumpy</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-adam-2-5" type="checkbox" value="YES" name="adam[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-adam-2-5">Erections Less Strong</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-adam-2-6" type="checkbox" value="YES" name="adam[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-adam-2-6">Recent Deterioration in Ability to Play Sports</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-adam-2-7" type="checkbox" value="YES" name="adam[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-adam-2-7">Recent Deterioration in Work Performance</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-adam-2-8" type="checkbox" value="YES" name="adam[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-adam-2-8">Falling Asleep Shortly After Dinner</label></div></fieldset></div><div class="fusion-form-field fusion-form-number-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><div class="fusion-form-label-wrapper"><label for="m_freq">Frequency of night urination (times per night)</label></div><input type="number" name="m_freq" id="m_freq" value="" class="fusion-form-input" data-holds-private-data="false" min="0" max="10"/></div><div class="fusion-form-field fusion-form-radio-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><div class="fusion-form-label-wrapper"><span class="label">Are you experiancing difficulty completing urination?</span></div><fieldset><div class="fusion-form-radio"><input tabindex="" id="radio-e_urine-1-0" type="radio" value="YES" name="e_urine" class="fusion-form-input" data-holds-private-data="false"/><label for="radio-e_urine-1-0">YES</label></div><div class="fusion-form-radio"><input tabindex="" id="radio-e_urine-1-1" type="radio" value="NO" name="e_urine" class="fusion-form-input" data-holds-private-data="false"/><label for="radio-e_urine-1-1">NO</label></div></fieldset></div><div class="fusion-form-field fusion-form-radio-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><div class="fusion-form-label-wrapper"><span class="label">Have you recently noticed any lumps, swelling, tenderness or pain in your testicles?</span></div><fieldset><div class="fusion-form-radio"><input tabindex="" id="radio-m_lump-2-0" type="radio" value="YES" name="m_lump" class="fusion-form-input" data-holds-private-data="false"/><label for="radio-m_lump-2-0">YES</label></div><div class="fusion-form-radio"><input tabindex="" id="radio-m_lump-2-1" type="radio" value="NO" name="m_lump" class="fusion-form-input" data-holds-private-data="false"/><label for="radio-m_lump-2-1">NO</label></div></fieldset></div><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><label for="m_pros">Results from your last prostate exam (if applicable)</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="m_pros" name="m_pros" class="fusion-form-input" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-29{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-29 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-29{width:100% !important;order : 0;}.fusion-builder-column-29 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-29{width:100% !important;order : 0;}.fusion-builder-column-29 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-30 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-checkbox-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><div class="fusion-form-label-wrapper"><span class="label">Do you suffer from any of the following conditions? (select all that apply)</span></div><fieldset><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-eve-3-0" type="checkbox" value="YES" name="eve[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-eve-3-0">Hot Flashes</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-eve-3-1" type="checkbox" value="YES" name="eve[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-eve-3-1">Lack of Energy</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-eve-3-2" type="checkbox" value="YES" name="eve[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-eve-3-2">Diminished Sex Drive</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-eve-3-3" type="checkbox" value="YES" name="eve[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-eve-3-3">Decreased Enjoyment of Life</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-eve-3-4" type="checkbox" value="YES" name="eve[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-eve-3-4">Moody or Easily Irritated</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-eve-3-5" type="checkbox" value="YES" name="eve[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-eve-3-5">Difficulty concentrating / shot-term memory loss</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-eve-3-6" type="checkbox" value="YES" name="eve[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-eve-3-6">Muscle Loss</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-eve-3-7" type="checkbox" value="YES" name="eve[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-eve-3-7">Bladder Leakage</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-eve-3-8" type="checkbox" value="YES" name="eve[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-eve-3-8">Excess Bodyfat</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-eve-3-9" type="checkbox" value="YES" name="eve[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-eve-3-9">Restless Sleep / Sleep Disturbances</label></div></fieldset></div><div class="fusion-form-field fusion-form-radio-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><div class="fusion-form-label-wrapper"><span class="label">Do you suffer from heavy, irregular or painful periods?</span></div><fieldset><div class="fusion-form-radio"><input tabindex="" id="radio-w_hp-3-0" type="radio" value="YES" name="w_hp" class="fusion-form-input" data-holds-private-data="false"/><label for="radio-w_hp-3-0">YES</label></div><div class="fusion-form-radio"><input tabindex="" id="radio-w_hp-3-1" type="radio" value="NO" name="w_hp" class="fusion-form-input" data-holds-private-data="false"/><label for="radio-w_hp-3-1">NO</label></div></fieldset></div><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><label for="w_if_hp">Please list symptoms</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="w_if_hp" name="w_if_hp" class="fusion-form-input" data-holds-private-data="false"></textarea></div><div class="fusion-form-field fusion-form-date-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><label for="w_mp">Date of last menstrual period</label><input autocomplete="no" type="date" data-format="" tabindex="" id="w_mp" name="w_mp" data-type="custom" value="" data-holds-private-data="false" class="fusion-form-input"autocomplete="no"/></div></div><style type="text/css">.fusion-body .fusion-builder-column-30{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-30 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-30{width:100% !important;order : 0;}.fusion-builder-column-30 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-30{width:100% !important;order : 0;}.fusion-builder-column-30 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-31 fusion_builder_column_1_2 1_2 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-radio-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><div class="fusion-form-label-wrapper"><span class="label">Are you currently pregnant or breastfeeding?</span></div><fieldset><div class="fusion-form-radio"><input tabindex="" id="radio-w_preg-4-0" type="radio" value="YES" name="w_preg" class="fusion-form-input" data-holds-private-data="false"/><label for="radio-w_preg-4-0">YES</label></div><div class="fusion-form-radio"><input tabindex="" id="radio-w_preg-4-1" type="radio" value="NO" name="w_preg" class="fusion-form-input" data-holds-private-data="false"/><label for="radio-w_preg-4-1">NO</label></div></fieldset></div></div><style type="text/css">.fusion-body .fusion-builder-column-31{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-31 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-31{width:50% !important;order : 0;}.fusion-builder-column-31 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-31{width:100% !important;order : 0;}.fusion-builder-column-31 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-32 fusion_builder_column_1_2 1_2 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-number-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><div class="fusion-form-label-wrapper"><label for="w_num_p">Number of Pregnancies</label></div><input type="number" name="w_num_p" id="w_num_p" value="" class="fusion-form-input" data-holds-private-data="false" min="0" max="10"/></div></div><style type="text/css">.fusion-body .fusion-builder-column-32{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-32 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-32{width:50% !important;order : 0;}.fusion-builder-column-32 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-32{width:100% !important;order : 0;}.fusion-builder-column-32 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-33 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><label for="conceive">Do you have plans to conceive soon? If no, what are you using for birth control?</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="conceive" name="conceive" class="fusion-form-input" data-holds-private-data="false"></textarea></div><div class="fusion-form-field fusion-form-radio-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><div class="fusion-form-label-wrapper"><span class="label">Do you suffer from frequent bladder or kidney infections?</span></div><fieldset><div class="fusion-form-radio"><input tabindex="" id="radio-w_blad-5-0" type="radio" value="YES" name="w_blad" class="fusion-form-input" data-holds-private-data="false"/><label for="radio-w_blad-5-0">YES</label></div><div class="fusion-form-radio"><input tabindex="" id="radio-w_blad-5-1" type="radio" value="NO" name="w_blad" class="fusion-form-input" data-holds-private-data="false"/><label for="radio-w_blad-5-1">NO</label></div></fieldset></div><div class="fusion-form-field fusion-form-radio-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><div class="fusion-form-label-wrapper"><span class="label">Have you recently note any breast lumps, tenderness, pain or nipple discharge?</span></div><fieldset><div class="fusion-form-radio"><input tabindex="" id="radio-w_lump-6-0" type="radio" value="YES" name="w_lump" class="fusion-form-input" data-holds-private-data="false"/><label for="radio-w_lump-6-0">YES</label></div><div class="fusion-form-radio"><input tabindex="" id="radio-w_lump-6-1" type="radio" value="NO" name="w_lump" class="fusion-form-input" data-holds-private-data="false"/><label for="radio-w_lump-6-1">NO</label></div></fieldset></div><div class="fusion-form-field fusion-form-date-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><label for="w_pap">Date of last pap smear</label><input autocomplete="no" type="date" data-format="" tabindex="" id="w_pap" name="w_pap" data-type="custom" value="" data-holds-private-data="false" class="fusion-form-input"autocomplete="no"/></div></div><style type="text/css">.fusion-body .fusion-builder-column-33{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-33 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-33{width:100% !important;order : 0;}.fusion-builder-column-33 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-33{width:100% !important;order : 0;}.fusion-builder-column-33 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-34 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#070707;padding: 0px 0px 0px 0px;"><div class="fusion-text fusion-text-6"><h3 style="font-family: Montserrat; font-weight: 400; font-size: 20px;" data-fusion-font="true" data-fusion-google-font="Montserrat" data-fusion-google-variant="400">Health Habits</h3> </div></div><style type="text/css">.fusion-body .fusion-builder-column-34{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-34 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-34{width:100% !important;order : 0;}.fusion-builder-column-34 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-34{width:100% !important;order : 0;}.fusion-builder-column-34 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-35 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above" data-form-id="31998"><label for="hh_ex">Current exercise regimen</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="hh_ex" name="hh_ex" class="fusion-form-input" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-35{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-35 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-35{width:100% !important;order : 0;}.fusion-builder-column-35 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-35{width:100% !important;order : 0;}.fusion-builder-column-35 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-36 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above" data-form-id="31998"><label for="hh_diet">Current diet model?</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="hh_diet" name="hh_diet" class="fusion-form-input" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-36{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-36 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-36{width:100% !important;order : 0;}.fusion-builder-column-36 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-36{width:100% !important;order : 0;}.fusion-builder-column-36 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-37 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above" data-form-id="31998"><label for="hh_caf">Current caffeine intake?</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="hh_caf" name="hh_caf" class="fusion-form-input" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-37{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-37 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-37{width:100% !important;order : 0;}.fusion-builder-column-37 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-37{width:100% !important;order : 0;}.fusion-builder-column-37 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-38 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above" data-form-id="31998"><label for="hh_tob">Tobacco intake?</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="hh_tob" name="hh_tob" class="fusion-form-input" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-38{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-38 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-38{width:100% !important;order : 0;}.fusion-builder-column-38 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-38{width:100% !important;order : 0;}.fusion-builder-column-38 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-39 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above" data-form-id="31998"><label for="hh_mj">Marijuana intake?</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="hh_mj" name="hh_mj" class="fusion-form-input" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-39{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-39 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-39{width:100% !important;order : 0;}.fusion-builder-column-39 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-39{width:100% !important;order : 0;}.fusion-builder-column-39 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-40 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-radio-field fusion-form-label-above" data-form-id="31998"><div class="fusion-form-label-wrapper"><span class="label">Illegal drug use?</span></div><fieldset><div class="fusion-form-radio option-inline"><input tabindex="" id="radio-hh_drug-7-0" type="radio" value="YES" name="hh_drug" class="fusion-form-input" data-holds-private-data="false"/><label for="radio-hh_drug-7-0">YES</label></div><div class="fusion-form-radio option-inline"><input tabindex="" id="radio-hh_drug-7-1" type="radio" value="NO" name="hh_drug" class="fusion-form-input" data-holds-private-data="false"/><label for="radio-hh_drug-7-1">NO</label></div></fieldset></div><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above fusion-form-field-hidden" data-form-id="31998"><label for="hh_use">Recreational drug intake? What? How often?</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="hh_use" name="hh_use" class="fusion-form-input" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-40{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-40 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-40{width:100% !important;order : 0;}.fusion-builder-column-40 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-40{width:100% !important;order : 0;}.fusion-builder-column-40 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-41 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#070707;padding: 0px 0px 0px 0px;"><div class="fusion-text fusion-text-7"><h3 style="font-family: Montserrat; font-weight: 400; font-size: 20px;" data-fusion-font="true" data-fusion-google-font="Montserrat" data-fusion-google-variant="400">Goals</h3> </div></div><style type="text/css">.fusion-body .fusion-builder-column-41{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-41 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-41{width:100% !important;order : 0;}.fusion-builder-column-41 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-41{width:100% !important;order : 0;}.fusion-builder-column-41 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-42 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-checkbox-field fusion-form-label-above" data-form-id="31998"><div class="fusion-form-label-wrapper"><span class="label">What are you interested in?</span></div><fieldset><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-g_i-4-0" type="checkbox" value="Hormone optimization" name="g_i[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-g_i-4-0">Hormone optimization</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-g_i-4-1" type="checkbox" value="Cognitive enhancement" name="g_i[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-g_i-4-1">Cognitive enhancement</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-g_i-4-2" type="checkbox" value="Sexual enhancement" name="g_i[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-g_i-4-2">Sexual enhancement</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-g_i-4-3" type="checkbox" value="Sleep optimization" name="g_i[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-g_i-4-3">Sleep optimization</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-g_i-4-4" type="checkbox" value="Longevity" name="g_i[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-g_i-4-4">Longevity</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-g_i-4-5" type="checkbox" value="Anti-ageing" name="g_i[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-g_i-4-5">Anti-ageing</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-g_i-4-6" type="checkbox" value="Fat Loss" name="g_i[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-g_i-4-6">Fat Loss</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-g_i-4-7" type="checkbox" value="Hair loss" name="g_i[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-g_i-4-7">Hair loss</label></div><div class="fusion-form-checkbox"><input tabindex="" id="checkbox-g_i-4-8" type="checkbox" value="Injury recovery" name="g_i[]" class="fusion-form-input" data-holds-private-data="false"/><label for="checkbox-g_i-4-8">Injury recovery</label></div></fieldset></div><div class="fusion-form-field fusion-form-text-field fusion-form-label-above" data-form-id="31998"><div class="fusion-form-label-wrapper"><label for="other">Other</label></div><input type="text" name="other" id="other" value="" class="fusion-form-input" data-holds-private-data="false" minlength="0"/></div></div><style type="text/css">.fusion-body .fusion-builder-column-42{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-42 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-42{width:100% !important;order : 0;}.fusion-builder-column-42 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-42{width:100% !important;order : 0;}.fusion-builder-column-42 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-43 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-textarea-field fusion-form-label-above" data-form-id="31998"><label for="g_d">What does your dream outcome working with Marek Health look like?</label><textarea cols="40" minlength="0" rows="4" tabindex="" id="g_d" name="g_d" class="fusion-form-input" data-holds-private-data="false"></textarea></div></div><style type="text/css">.fusion-body .fusion-builder-column-43{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-43 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-43{width:100% !important;order : 0;}.fusion-builder-column-43 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-43{width:100% !important;order : 0;}.fusion-builder-column-43 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-44 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-select-field fusion-form-label-above" data-form-id="31998"><label for="g_b">How much per year can you commit towards your dream outcome? <abbr class="fusion-form-element-required" title="required">*</abbr></label><div class="fusion-select-wrapper"><select tabindex="" id="g_b" name="g_b" class="fusion-form-input" required="true" aria-required="true" data-holds-private-data="false"><option value="$1000-2000" >$1000-2000</option><option value="$2000-3000" >$2000-3000</option><option value="$4000-6000" >$4000-6000</option><option value="$6000-10000" >$6000-10000</option><option value="$10000+" >$10000+</option></select><div class="select-arrow"><svg width="12" height="8" viewBox="0 0 12 8" fill="none" xmlns="http://www.w3.org/2000/svg"> <path d="M1.5 1.75L6 6.25L10.5 1.75" stroke="#6D6D6D" stroke-width="2" stroke-linecap="round" stroke-linejoin="round"/> </svg></div></div></div></div><style type="text/css">.fusion-body .fusion-builder-column-44{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-44 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-44{width:100% !important;order : 0;}.fusion-builder-column-44 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-44{width:100% !important;order : 0;}.fusion-builder-column-44 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-45 fusion_builder_column_1_1 1_1 fusion-flex-column file-up-div"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-upload-field fusion-form-label-above" data-form-id="31998"><label for="physical">Physical Exam Documents</label><div class="fusion-form-input-with-icon"><i class=" fa-upload fas"></i><div class="fusion-form-upload-field-container"><input type="file" id="physical" name="physical" value="" class="fusion-form-input" placeholder="Click or drag a file to this area to upload." data-size="20"/><input type="text" disabled value="" class="fusion-form-upload-field" placeholder="Click or drag a file to this area to upload." data-holds-private-data="false"/><div ><style>.fusion-button.button-1{border-radius:0px 0px 0px 0px;}</style><a class="fusion-button button-flat button-medium button-default button-1 fusion-button-default-span fusion-button-default-type fusion-form-upload-field-button" target="_self" href="javascript:void();"><span class="fusion-button-text">Choose File</span></a></div></div></div></div><div id="labwork" class="fusion-form-field fusion-form-upload-field fusion-form-label-above" data-form-id="31998"><label for="labs">Upload Diagnostic Labwork Results</label><div class="fusion-form-input-with-icon"><i class=" fa-upload fas"></i><div class="fusion-form-upload-field-container"><input type="file" id="labs" name="labs" value="" class="fusion-form-input" placeholder="Click or drag a file to this area to upload." data-size="18"/><input type="text" disabled value="" class="fusion-form-upload-field" placeholder="Click or drag a file to this area to upload." data-holds-private-data="false"/><div ><style>.fusion-button.button-2{border-radius:0px 0px 0px 0px;}</style><a class="fusion-button button-flat button-medium button-default button-2 fusion-button-default-span fusion-button-default-type fusion-form-upload-field-button" target="_self" href="javascript:void();"><span class="fusion-button-text">Choose File</span></a></div></div></div></div></div><style type="text/css">.fusion-body .fusion-builder-column-45{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-45 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-45{width:100% !important;order : 0;}.fusion-builder-column-45 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-45{width:100% !important;order : 0;}.fusion-builder-column-45 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-46 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-form-field fusion-form-checkbox-field fusion-form-label-above" data-form-id="31998"><fieldset><div class="fusion-form-checkbox option-inline"><input tabindex="" id="checkbox-legal_agree-5-0" type="checkbox" value="agree" name="legal_agree[]" class="fusion-form-input" required="true" aria-required="true" data-holds-private-data="false"/><label for="checkbox-legal_agree-5-0">I have read, understand, and agree with the <a href="https://marekhealth.com/terms-and-conditions/" target="_blank" style="text-decoration: underline; ">terms</a>, <a href="https://marekhealth.com/privacy" target="_blank" style="text-decoration: underline; ">privacy policy</a>, <a href="#" target="_blank" style="text-decoration: underline; ">notice of direct pay</a>, and <a href="#" target="_blank" style="text-decoration: underline; ">consent to telemedecine</a>.</label></div></fieldset></div><div id="submitBtn" class="fusion-form-field fusion-form-submit-field fusion-form-label-above" data-form-id="31998"><div style="text-align:center;"><style>.fusion-button.button-3{border-radius:0px 0px 0px 0px;}</style><button type="submit" class="fusion-button button-flat fusion-button-default-size button-default button-3 fusion-button-span-no form-form-submit button-default" data-form-number="31998" id="submitBtn" tabindex=""><span class="fusion-button-text">Submit</span></button></div></div></div><style type="text/css">.fusion-body .fusion-builder-column-46{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-46 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-46{width:100% !important;order : 0;}.fusion-builder-column-46 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-46{width:100% !important;order : 0;}.fusion-builder-column-46 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div></div><style type="text/css">.fusion-body .fusion-flex-container.fusion-builder-row-1{ padding-top : 0px;margin-top : 50PX;padding-right : 0px;padding-bottom : 0px;margin-bottom : 0px;padding-left : 0px;}</style></div><div class="fusion-fullwidth fullwidth-box fusion-builder-row-2 fusion-flex-container submitThanks nonhundred-percent-fullwidth non-hundred-percent-height-scrolling" style="background-color: #070707;background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#eae9e9;border-style:solid;" id="submitThanks" ><div class="fusion-builder-row fusion-row fusion-flex-align-items-flex-start" style="max-width:1248px;margin-left: calc(-4% / 2 );margin-right: calc(-4% / 2 );"><div class="fusion-layout-column fusion_builder_column fusion-builder-column-47 fusion_builder_column_1_1 1_1 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-separator" style="align-self: center;margin-left: auto;margin-right: auto;width:100%;max-width:10px;"><div class="fusion-separator-border sep-double" style="border-color:#e0dede;border-top-width:1px;border-bottom-width:1px;"></div></div><div class="fusion-text fusion-text-8" style="text-align:center;"><h4 style="text-align: center;">Thanks for your submission</h4> <h4 style="text-align: center;">We are generating your intake paperwork for signature below.</h4> </div></div><style type="text/css">.fusion-body .fusion-builder-column-47{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-47 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-47{width:100% !important;order : 0;}.fusion-builder-column-47 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-47{width:100% !important;order : 0;}.fusion-builder-column-47 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-48 fusion_builder_column_1_2 1_2 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div ><span class=" fusion-imageframe imageframe-none imageframe-1 hover-type-none loading-gif" id="loading-gif"><img width="1181" height="1181" title="loading" src="https://marekhealth.com/wp-content/uploads/2021/11/loading.gif" alt class="img-responsive wp-image-31710"/></span></div><iframe id="pandaFrame" width='100%' height='425px' frameBorder="0"></iframe> <script> window.addEventListener('message', (event) => { const type = event.data && event.data.type; const payload = event.data && event.data.payload; switch (type) { case 'session_view.document.loaded': console.log('Session view is loaded'); break; case 'session_view.document.completed': console.log('Document is completed'); console.log(payload); break; case 'session_view.document.exception': console.log('Exception during document finalization'); console.log(payload); } }); </script></div><style type="text/css">.fusion-body .fusion-builder-column-48{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-48 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-48{width:50% !important;order : 0;}.fusion-builder-column-48 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-48{width:100% !important;order : 0;}.fusion-builder-column-48 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div><div class="fusion-layout-column fusion_builder_column fusion-builder-column-49 fusion_builder_column_1_2 1_2 fusion-flex-column"><div class="fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column" style="background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;"><div class="fusion-text fusion-text-9" style="text-align:center;"><h3 style="text-align: center;">After Signing the Document</h3> </div><div style="text-align:center;"><style>.fusion-button.button-4{border-radius:0px 0px 0px 0px;}</style><a class="fusion-button button-flat fusion-button-default-size button-default button-4 fusion-button-default-span fusion-button-default-type" target="_self" href="https://bookings.marekhealth.com/#/customer/paidintake"><span class="fusion-button-text">Book Intake Meeting</span></a></div></div><style type="text/css">.fusion-body .fusion-builder-column-49{width:50% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-49 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-49{width:50% !important;order : 0;}.fusion-builder-column-49 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-49{width:100% !important;order : 0;}.fusion-builder-column-49 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}</style></div></div><style type="text/css">.fusion-body .fusion-flex-container.fusion-builder-row-2{ padding-top : 0px;margin-top : 0px;padding-right : 0px;padding-bottom : 0px;margin-bottom : 0px;padding-left : 0px;}</style></div><input type="hidden" name="fusion_privacy_store_ip_ua" value="false"><input type="hidden" name="fusion_privacy_expiration_interval" value="48"><input type="hidden" name="privacy_expiration_action" value="anonymize"></form></div>