{"id":2407,"date":"2025-12-10T13:09:20","date_gmt":"2025-12-10T21:09:20","guid":{"rendered":"https:\/\/anaheimelementary.org\/pupil-services\/?page_id=2407"},"modified":"2026-03-20T11:20:10","modified_gmt":"2026-03-20T18:20:10","slug":"health-history-form","status":"publish","type":"page","link":"https:\/\/anaheimelementary.org\/pupil-services\/health-history-form\/","title":{"rendered":"Health History Form"},"content":{"rendered":"\n<p class=\"py-2\">Please complete only if your child has a health condition. Completing the Health History Form below will prompt the school nurse to ensure appropriate supports are in place to help your child fully access their education.<\/p>\n\n\n\n<div style=\"height:25px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\r\n<div   \r\n  class=\"p-4 border shadow-md bg-base-200\/50 rounded-xl border-base-300\"\r\n  data-wp-interactive=\"aesd\/health-history-form\"\r\n  data-wp-context='{ \"formId\": \"health-history-form-1\" }'\r\n  data-wp-init=\"callbacks.init\"\r\n  id=\"health-history-form-wrapper\"\r\n>\r\n  <form \r\n    id=\"health-history-form-1\" \r\n    class=\"space-y-4\" \r\n    data-wp-on--submit=\"actions.submitForm\"\r\n  >\r\n      \r\n    <!-- General Health History -->\r\n        <fieldset id=\"general-fields-wrapper\" class=\"grid grid-cols-12 gap-4\">\r\n                    <legend class=\"col-span-12 mb-4 text-2xl font-bold\">\r\n                Student &amp; Parent Information            <\/legend>\r\n        \r\n        <div class=\"col-span-6\" data-wp-context='{\"isValid\": true, \"isRequired\": true }'><label for=\"health-history-form-1-student_first_name\" class=\"block\">Student First Name <span aria-hidden=\"true\" class=\"font-bold text-red-600\">*<\/span><\/label><input aria-invalid=\"false\" value=\"\" type=\"text\" id=\"health-history-form-1-student_first_name\" name=\"student_first_name\" class=\"w-full input\" required aria-required=\"true\" aria-describedby=\"health-history-form-1-student_first_name-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.student_first_name\" data-wp-on--input=\"actions.updateGeneralField\"><div hidden id=\"health-history-form-1-student_first_name-error\" class=\"text-sm text-error min-h-5\" role=\"alert\" data-wp-bind--hidden=\"context.isValid\">This field is required<\/div><\/div><div class=\"col-span-6\" data-wp-context='{\"isValid\": true, \"isRequired\": true }'><label for=\"health-history-form-1-student_last_name\" class=\"block\">Student Last Name <span aria-hidden=\"true\" class=\"font-bold text-red-600\">*<\/span><\/label><input aria-invalid=\"false\" value=\"\" type=\"text\" id=\"health-history-form-1-student_last_name\" name=\"student_last_name\" class=\"w-full input\" required aria-required=\"true\" aria-describedby=\"health-history-form-1-student_last_name-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.student_last_name\" data-wp-on--input=\"actions.updateGeneralField\"><div hidden id=\"health-history-form-1-student_last_name-error\" class=\"text-sm text-error min-h-5\" role=\"alert\" data-wp-bind--hidden=\"context.isValid\">This field is required<\/div><\/div><div class=\"col-span-6\" data-wp-context='{\"isValid\": true, \"isRequired\": true }'><label for=\"health-history-form-1-student_date_of_birth\" class=\"block\">Student Date of Birth <span aria-hidden=\"true\" class=\"font-bold text-red-600\">*<\/span><\/label><input aria-invalid=\"false\" value=\"\" type=\"date\" id=\"health-history-form-1-student_date_of_birth\" name=\"student_date_of_birth\" class=\"w-full input\" required aria-required=\"true\" aria-describedby=\"health-history-form-1-student_date_of_birth-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.student_date_of_birth\" data-wp-on--input=\"actions.updateGeneralField\"><div hidden id=\"health-history-form-1-student_date_of_birth-error\" class=\"text-sm text-error min-h-5\" role=\"alert\" data-wp-bind--hidden=\"context.isValid\">This field is required<\/div><\/div><div class=\"col-span-6\" data-wp-context='{\"isValid\": true, \"isRequired\": true }'><label for=\"health-history-form-1-student_current_grade\" class=\"block\">Current Grade <span aria-hidden=\"true\" class=\"font-bold text-red-600\">*<\/span><\/label><select aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-student_current_grade\" name=\"student_current_grade\" class=\"w-full select\" required aria-required=\"true\" aria-describedby=\"health-history-form-1-student_current_grade-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateSelectField\" data-wp-class--select-error=\"!context.isValid\" data-wp-bind--value=\"state.data.student_current_grade\" data-wp-on--change=\"actions.updateGeneralField\"><option value=\"\">Select Grade<\/option><option value=\"tk\">Transitional Kindergarten<\/option><option value=\"k\">Kindergarten<\/option><option value=\"1\">1st Grade<\/option><option value=\"2\">2nd Grade<\/option><option value=\"3\">3rd Grade<\/option><option value=\"4\">4th Grade<\/option><option value=\"5\">5th Grade<\/option><option value=\"6\">6th Grade<\/option><\/select><div hidden id=\"health-history-form-1-student_current_grade-error\" class=\"text-sm text-error min-h-5\" role=\"alert\" data-wp-bind--hidden=\"context.isValid\">This field is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": true }'><label for=\"health-history-form-1-student_school\" class=\"block\">School <span aria-hidden=\"true\" class=\"font-bold text-red-600\">*<\/span><\/label><select aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-student_school\" name=\"student_school\" class=\"w-full select\" required aria-required=\"true\" aria-describedby=\"health-history-form-1-student_school-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateSelectField\" data-wp-class--select-error=\"!context.isValid\" data-wp-bind--value=\"state.data.student_school\" data-wp-on--change=\"actions.updateGeneralField\"><option value=\"\">Select School<\/option><option value=\"barton\">Barton<\/option><option value=\"edison\">Edison<\/option><option value=\"franklin\">Franklin<\/option><option value=\"gauer\">Gauer<\/option><option value=\"guinn\">Guinn<\/option><option value=\"henry\">Henry<\/option><option value=\"jefferson\">Jefferson<\/option><option value=\"juarez\">Juarez<\/option><option value=\"lincoln\">Lincoln<\/option><option value=\"loara\">Loara<\/option><option value=\"madison\">Madison<\/option><option value=\"mann\">Mann<\/option><option value=\"marshall\">Marshall<\/option><option value=\"olive-street\">Olive Street<\/option><option value=\"orange-grove\">Orange Grove<\/option><option value=\"ponderosa\">Ponderosa<\/option><option value=\"price\">Price<\/option><option value=\"revere\">Revere<\/option><option value=\"roosevelt\">Roosevelt<\/option><option value=\"ross\">Ross<\/option><option value=\"stoddard\">Stoddard<\/option><option value=\"sunkist\">Sunkist<\/option><option value=\"westmont\">Westmont<\/option><\/select><div hidden id=\"health-history-form-1-student_school-error\" class=\"text-sm text-error min-h-5\" role=\"alert\" data-wp-bind--hidden=\"context.isValid\">This field is required<\/div><\/div><div class=\"col-span-6\" data-wp-context='{\"isValid\": true, \"isRequired\": true }'><label for=\"health-history-form-1-parent_first_name\" class=\"block\">Parent\/Guardian First Name <span aria-hidden=\"true\" class=\"font-bold text-red-600\">*<\/span><\/label><input aria-invalid=\"false\" value=\"\" type=\"text\" id=\"health-history-form-1-parent_first_name\" name=\"parent_first_name\" class=\"w-full input\" required aria-required=\"true\" aria-describedby=\"health-history-form-1-parent_first_name-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.parent_first_name\" data-wp-on--input=\"actions.updateGeneralField\"><div hidden id=\"health-history-form-1-parent_first_name-error\" class=\"text-sm text-error min-h-5\" role=\"alert\" data-wp-bind--hidden=\"context.isValid\">This field is required<\/div><\/div><div class=\"col-span-6\" data-wp-context='{\"isValid\": true, \"isRequired\": true }'><label for=\"health-history-form-1-parent_last_name\" class=\"block\">Parent\/Guardian Last Name <span aria-hidden=\"true\" class=\"font-bold text-red-600\">*<\/span><\/label><input aria-invalid=\"false\" value=\"\" type=\"text\" id=\"health-history-form-1-parent_last_name\" name=\"parent_last_name\" class=\"w-full input\" required aria-required=\"true\" aria-describedby=\"health-history-form-1-parent_last_name-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.parent_last_name\" data-wp-on--input=\"actions.updateGeneralField\"><div hidden id=\"health-history-form-1-parent_last_name-error\" class=\"text-sm text-error min-h-5\" role=\"alert\" data-wp-bind--hidden=\"context.isValid\">This field is required<\/div><\/div><div class=\"col-span-6\" data-wp-context='{\"isValid\": true, \"isRequired\": true }'><label for=\"health-history-form-1-parent_email\" class=\"block\">Parent\/Guardian Email <span aria-hidden=\"true\" class=\"font-bold text-red-600\">*<\/span><\/label><input aria-invalid=\"false\" value=\"\" type=\"email\" id=\"health-history-form-1-parent_email\" name=\"parent_email\" class=\"w-full input\" required aria-required=\"true\" aria-describedby=\"health-history-form-1-parent_email-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.parent_email\" data-wp-on--input=\"actions.updateGeneralField\"><div hidden id=\"health-history-form-1-parent_email-error\" class=\"text-sm text-error min-h-5\" role=\"alert\" data-wp-bind--hidden=\"context.isValid\">This field is required<\/div><\/div><div class=\"col-span-6\" data-wp-context='{\"isValid\": true, \"isRequired\": true }'><label for=\"health-history-form-1-parent_phone\" class=\"block\">Parent\/Guardian Phone <span aria-hidden=\"true\" class=\"font-bold text-red-600\">*<\/span><\/label><input aria-invalid=\"false\" value=\"\" type=\"tel\" id=\"health-history-form-1-parent_phone\" name=\"parent_phone\" class=\"w-full input\" required aria-required=\"true\" aria-describedby=\"health-history-form-1-parent_phone-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.parent_phone\" data-wp-on--input=\"actions.updateGeneralField\"><div hidden id=\"health-history-form-1-parent_phone-error\" class=\"text-sm text-error min-h-5\" role=\"alert\" data-wp-bind--hidden=\"context.isValid\">This field is required<\/div><\/div>    <\/fieldset>\r\n\r\n    <!-- Health Conditions Selection -->\r\n    <fieldset id=\"health-conditions-wrapper\" class=\"grid items-start grid-cols-1 gap-3 sm:grid-cols-2 lg:grid-cols-3 gap-x-3\">\r\n    <legend class=\"col-span-12 mb-0 text-2xl font-bold\">Health Conditions<\/legend>\r\n    <p class=\"col-span-12 mb-0\">Please select any conditions diagnosed by a doctor that apply to the student.<\/p>\r\n\r\n            <div\r\n            class=\"col-span-4\"\r\n            data-wp-context='{\"conditionKey\": \"anaphylaxis\"}'\r\n        >\r\n            <label \r\n                for=\"health-history-form-1-condition-anaphylaxis\"\r\n                class=\"flex items-center p-3 transition-colors border-2 rounded-lg cursor-pointer label border-base-300 hover:bg-base-200\"\r\n            >\r\n                <input\r\n                    type=\"checkbox\"\r\n                    id=\"health-history-form-1-condition-anaphylaxis\"\r\n                    name=\"condition_anaphylaxis\"\r\n                    value=\"anaphylaxis\"\r\n                    data-wp-on--change=\"actions.toggleFieldSet\"\r\n                    data-wp-bind--checked=\"state.data.conditions.anaphylaxis.enabled\"\r\n                    class=\"checkbox bg-base-100 shrink-0 no-animation\"\r\n                    aria-label=\"Enable Allergies (Anaphylaxis) section\"\r\n                \/>\r\n                <span class=\"ml-3 label-text text-balance\">\r\n                    Allergies (Anaphylaxis)                <\/span>\r\n            <\/label>\r\n        <\/div>\r\n            <div\r\n            class=\"col-span-4\"\r\n            data-wp-context='{\"conditionKey\": \"asthma\"}'\r\n        >\r\n            <label \r\n                for=\"health-history-form-1-condition-asthma\"\r\n                class=\"flex items-center p-3 transition-colors border-2 rounded-lg cursor-pointer label border-base-300 hover:bg-base-200\"\r\n            >\r\n                <input\r\n                    type=\"checkbox\"\r\n                    id=\"health-history-form-1-condition-asthma\"\r\n                    name=\"condition_asthma\"\r\n                    value=\"asthma\"\r\n                    data-wp-on--change=\"actions.toggleFieldSet\"\r\n                    data-wp-bind--checked=\"state.data.conditions.asthma.enabled\"\r\n                    class=\"checkbox bg-base-100 shrink-0 no-animation\"\r\n                    aria-label=\"Enable Asthma section\"\r\n                \/>\r\n                <span class=\"ml-3 label-text text-balance\">\r\n                    Asthma                <\/span>\r\n            <\/label>\r\n        <\/div>\r\n            <div\r\n            class=\"col-span-4\"\r\n            data-wp-context='{\"conditionKey\": \"heart_condition\"}'\r\n        >\r\n            <label \r\n                for=\"health-history-form-1-condition-heart_condition\"\r\n                class=\"flex items-center p-3 transition-colors border-2 rounded-lg cursor-pointer label border-base-300 hover:bg-base-200\"\r\n            >\r\n                <input\r\n                    type=\"checkbox\"\r\n                    id=\"health-history-form-1-condition-heart_condition\"\r\n                    name=\"condition_heart_condition\"\r\n                    value=\"heart_condition\"\r\n                    data-wp-on--change=\"actions.toggleFieldSet\"\r\n                    data-wp-bind--checked=\"state.data.conditions.heart_condition.enabled\"\r\n                    class=\"checkbox bg-base-100 shrink-0 no-animation\"\r\n                    aria-label=\"Enable Heart Condition section\"\r\n                \/>\r\n                <span class=\"ml-3 label-text text-balance\">\r\n                    Heart Condition                <\/span>\r\n            <\/label>\r\n        <\/div>\r\n            <div\r\n            class=\"col-span-4\"\r\n            data-wp-context='{\"conditionKey\": \"diabetes\"}'\r\n        >\r\n            <label \r\n                for=\"health-history-form-1-condition-diabetes\"\r\n                class=\"flex items-center p-3 transition-colors border-2 rounded-lg cursor-pointer label border-base-300 hover:bg-base-200\"\r\n            >\r\n                <input\r\n                    type=\"checkbox\"\r\n                    id=\"health-history-form-1-condition-diabetes\"\r\n                    name=\"condition_diabetes\"\r\n                    value=\"diabetes\"\r\n                    data-wp-on--change=\"actions.toggleFieldSet\"\r\n                    data-wp-bind--checked=\"state.data.conditions.diabetes.enabled\"\r\n                    class=\"checkbox bg-base-100 shrink-0 no-animation\"\r\n                    aria-label=\"Enable Diabetes section\"\r\n                \/>\r\n                <span class=\"ml-3 label-text text-balance\">\r\n                    Diabetes                <\/span>\r\n            <\/label>\r\n        <\/div>\r\n            <div\r\n            class=\"col-span-4\"\r\n            data-wp-context='{\"conditionKey\": \"hemophilia\"}'\r\n        >\r\n            <label \r\n                for=\"health-history-form-1-condition-hemophilia\"\r\n                class=\"flex items-center p-3 transition-colors border-2 rounded-lg cursor-pointer label border-base-300 hover:bg-base-200\"\r\n            >\r\n                <input\r\n                    type=\"checkbox\"\r\n                    id=\"health-history-form-1-condition-hemophilia\"\r\n                    name=\"condition_hemophilia\"\r\n                    value=\"hemophilia\"\r\n                    data-wp-on--change=\"actions.toggleFieldSet\"\r\n                    data-wp-bind--checked=\"state.data.conditions.hemophilia.enabled\"\r\n                    class=\"checkbox bg-base-100 shrink-0 no-animation\"\r\n                    aria-label=\"Enable Hemophilia section\"\r\n                \/>\r\n                <span class=\"ml-3 label-text text-balance\">\r\n                    Hemophilia                <\/span>\r\n            <\/label>\r\n        <\/div>\r\n            <div\r\n            class=\"col-span-4\"\r\n            data-wp-context='{\"conditionKey\": \"juvenile_idiopathic_arthritis\"}'\r\n        >\r\n            <label \r\n                for=\"health-history-form-1-condition-juvenile_idiopathic_arthritis\"\r\n                class=\"flex items-center p-3 transition-colors border-2 rounded-lg cursor-pointer label border-base-300 hover:bg-base-200\"\r\n            >\r\n                <input\r\n                    type=\"checkbox\"\r\n                    id=\"health-history-form-1-condition-juvenile_idiopathic_arthritis\"\r\n                    name=\"condition_juvenile_idiopathic_arthritis\"\r\n                    value=\"juvenile_idiopathic_arthritis\"\r\n                    data-wp-on--change=\"actions.toggleFieldSet\"\r\n                    data-wp-bind--checked=\"state.data.conditions.juvenile_idiopathic_arthritis.enabled\"\r\n                    class=\"checkbox bg-base-100 shrink-0 no-animation\"\r\n                    aria-label=\"Enable Juvenile Idiopathic Arthritis (JIA) section\"\r\n                \/>\r\n                <span class=\"ml-3 label-text text-balance\">\r\n                    Juvenile Idiopathic Arthritis (JIA)                <\/span>\r\n            <\/label>\r\n        <\/div>\r\n            <div\r\n            class=\"col-span-4\"\r\n            data-wp-context='{\"conditionKey\": \"nephrotic_syndrome\"}'\r\n        >\r\n            <label \r\n                for=\"health-history-form-1-condition-nephrotic_syndrome\"\r\n                class=\"flex items-center p-3 transition-colors border-2 rounded-lg cursor-pointer label border-base-300 hover:bg-base-200\"\r\n            >\r\n                <input\r\n                    type=\"checkbox\"\r\n                    id=\"health-history-form-1-condition-nephrotic_syndrome\"\r\n                    name=\"condition_nephrotic_syndrome\"\r\n                    value=\"nephrotic_syndrome\"\r\n                    data-wp-on--change=\"actions.toggleFieldSet\"\r\n                    data-wp-bind--checked=\"state.data.conditions.nephrotic_syndrome.enabled\"\r\n                    class=\"checkbox bg-base-100 shrink-0 no-animation\"\r\n                    aria-label=\"Enable Nephrotic Syndrome section\"\r\n                \/>\r\n                <span class=\"ml-3 label-text text-balance\">\r\n                    Nephrotic Syndrome                <\/span>\r\n            <\/label>\r\n        <\/div>\r\n            <div\r\n            class=\"col-span-4\"\r\n            data-wp-context='{\"conditionKey\": \"seizure_history\"}'\r\n        >\r\n            <label \r\n                for=\"health-history-form-1-condition-seizure_history\"\r\n                class=\"flex items-center p-3 transition-colors border-2 rounded-lg cursor-pointer label border-base-300 hover:bg-base-200\"\r\n            >\r\n                <input\r\n                    type=\"checkbox\"\r\n                    id=\"health-history-form-1-condition-seizure_history\"\r\n                    name=\"condition_seizure_history\"\r\n                    value=\"seizure_history\"\r\n                    data-wp-on--change=\"actions.toggleFieldSet\"\r\n                    data-wp-bind--checked=\"state.data.conditions.seizure_history.enabled\"\r\n                    class=\"checkbox bg-base-100 shrink-0 no-animation\"\r\n                    aria-label=\"Enable Seizure History section\"\r\n                \/>\r\n                <span class=\"ml-3 label-text text-balance\">\r\n                    Seizure History                <\/span>\r\n            <\/label>\r\n        <\/div>\r\n            <div\r\n            class=\"col-span-4\"\r\n            data-wp-context='{\"conditionKey\": \"other_health_conditions\"}'\r\n        >\r\n            <label \r\n                for=\"health-history-form-1-condition-other_health_conditions\"\r\n                class=\"flex items-center p-3 transition-colors border-2 rounded-lg cursor-pointer label border-base-300 hover:bg-base-200\"\r\n            >\r\n                <input\r\n                    type=\"checkbox\"\r\n                    id=\"health-history-form-1-condition-other_health_conditions\"\r\n                    name=\"condition_other_health_conditions\"\r\n                    value=\"other_health_conditions\"\r\n                    data-wp-on--change=\"actions.toggleFieldSet\"\r\n                    data-wp-bind--checked=\"state.data.conditions.other_health_conditions.enabled\"\r\n                    class=\"checkbox bg-base-100 shrink-0 no-animation\"\r\n                    aria-label=\"Enable Other Health Conditions section\"\r\n                \/>\r\n                <span class=\"ml-3 label-text text-balance\">\r\n                    Other Health Conditions                <\/span>\r\n            <\/label>\r\n        <\/div>\r\n                \r\n<\/fieldset>\r\n\r\n    <!-- Dynamic Condition Contents -->      \r\n\r\n    <!-- Allergies (Anaphylaxis) -->    \r\n        <fieldset aria-hidden=\"true\" disabled hidden\n        id=\"health-history-form-1-condition-anaphylaxis\"\n        class=\"block md:grid md:grid-cols-12 md:items-center gap-x-5 gap-y-3 bg-base-300\/50 p-4 rounded-lg mb-6\"\n        data-wp-context='{\"conditionKey\": \"anaphylaxis\"}'\n        data-wp-bind--hidden=\"!state.data.conditions.anaphylaxis.enabled\"\n        data-wp-bind--disabled=\"!state.data.conditions.anaphylaxis.enabled\"\n        data-wp-bind--aria-hidden=\"!state.data.conditions.anaphylaxis.enabled\"\n    >\n        <legend class=\"sticky top-5 z-50 fieldset-legend bg-info text-info-content px-4 py-1 text-xs rounded-full\">\n            Allergies (Anaphylaxis)        <\/legend>\n\n        <div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-anaphylaxis_allergic_substance\" class=\"block mb-2 font-medium\">1. Substance causing allergic reaction?<\/label><input aria-invalid=\"false\" value=\"\" type=\"text\" id=\"health-history-form-1-anaphylaxis_allergic_substance\" name=\"anaphylaxis_allergic_substance\" class=\"w-full input\" placeholder=\"e.g., peanuts, shellfish, bee stings, medications, eggs, sesame, latex etc.\" aria-describedby=\"health-history-form-1-anaphylaxis_allergic_substance-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.anaphylaxis.allergic_substance\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"anaphylaxis\" data-field-key=\"allergic_substance\"><div id=\"health-history-form-1-anaphylaxis_allergic_substance-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Substance causing allergic reaction? is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-anaphylaxis_age_diagnosis\" class=\"block mb-2 font-medium\">2. Age of diagnosis?<\/label><input aria-invalid=\"false\" value=\"\" type=\"number\" id=\"health-history-form-1-anaphylaxis_age_diagnosis\" name=\"anaphylaxis_age_diagnosis\" class=\"w-full input\" aria-describedby=\"health-history-form-1-anaphylaxis_age_diagnosis-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.anaphylaxis.age_diagnosis\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"anaphylaxis\" data-field-key=\"age_diagnosis\"><div id=\"health-history-form-1-anaphylaxis_age_diagnosis-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Age of diagnosis? is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">3. Is your child currently under a physician's care for this allergy?<\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-anaphylaxis_under_physician_care-yes\" name=\"anaphylaxis_under_physician_care\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-anaphylaxis_under_physician_care-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.anaphylaxis.under_physician_care === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"anaphylaxis\" data-field-key=\"under_physician_care\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-anaphylaxis_under_physician_care-no\" name=\"anaphylaxis_under_physician_care\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-anaphylaxis_under_physician_care-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.anaphylaxis.under_physician_care === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"anaphylaxis\" data-field-key=\"under_physician_care\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-anaphylaxis_under_physician_care-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Is your child currently under a physician's care for this allergy? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-anaphylaxis_reaction_count\" class=\"block mb-2 font-medium\">4. How many allergic reactions has your child had?<\/label><input aria-invalid=\"false\" value=\"\" type=\"text\" id=\"health-history-form-1-anaphylaxis_reaction_count\" name=\"anaphylaxis_reaction_count\" class=\"w-full input\" placeholder=\"e.g., 2, several, unknown\" aria-describedby=\"health-history-form-1-anaphylaxis_reaction_count-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.anaphylaxis.reaction_count\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"anaphylaxis\" data-field-key=\"reaction_count\"><div id=\"health-history-form-1-anaphylaxis_reaction_count-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">How many allergic reactions has your child had? is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">5. Does your child need special meal accommodations at school? <br \/> <span class='text-sm'>(If yes, please also complete the '<a class=\"font-semibold text-blue-900 underline hover:text-gray-500\"  href='https:\/\/drive.google.com\/file\/d\/1duFLA0uvNddNureO94HA225Um9FcfYHJ\/view?usp=sharing' target='_blank'>Medical Statement to Request Special Meal Accommodations<\/a>' form)<\/span><\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-anaphylaxis_needs_meal_accommodations-yes\" name=\"anaphylaxis_needs_meal_accommodations\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-anaphylaxis_needs_meal_accommodations-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.anaphylaxis.needs_meal_accommodations === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"anaphylaxis\" data-field-key=\"needs_meal_accommodations\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-anaphylaxis_needs_meal_accommodations-no\" name=\"anaphylaxis_needs_meal_accommodations\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-anaphylaxis_needs_meal_accommodations-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.anaphylaxis.needs_meal_accommodations === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"anaphylaxis\" data-field-key=\"needs_meal_accommodations\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-anaphylaxis_needs_meal_accommodations-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Does your child need special meal accommodations at school? <br \/> <span class='text-sm'>(If yes, please also complete the '<a class=\"font-semibold text-blue-900 underline hover:text-gray-500\"  href='https:\/\/drive.google.com\/file\/d\/1duFLA0uvNddNureO94HA225Um9FcfYHJ\/view?usp=sharing' target='_blank'>Medical Statement to Request Special Meal Accommodations<\/a>' form)<\/span> is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-3 font-medium\">6. Which of the following symptoms has your child experienced?<\/legend><div class=\"grid grid-cols-1 gap-2 sm:grid-cols-2\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-anaphylaxis_symptoms_experienced-redness_swelling\" name=\"anaphylaxis_symptoms_experienced[]\" value=\"redness_swelling\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-anaphylaxis_symptoms_experienced-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.anaphylaxis.symptoms_experienced && state.data.conditions.anaphylaxis.symptoms_experienced.includes('redness_swelling')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"anaphylaxis\" data-field-key=\"symptoms_experienced\"><span>Redness and swelling of face<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-anaphylaxis_symptoms_experienced-coughing\" name=\"anaphylaxis_symptoms_experienced[]\" value=\"coughing\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-anaphylaxis_symptoms_experienced-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.anaphylaxis.symptoms_experienced && state.data.conditions.anaphylaxis.symptoms_experienced.includes('coughing')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"anaphylaxis\" data-field-key=\"symptoms_experienced\"><span>Coughing<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-anaphylaxis_symptoms_experienced-hives\" name=\"anaphylaxis_symptoms_experienced[]\" value=\"hives\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-anaphylaxis_symptoms_experienced-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.anaphylaxis.symptoms_experienced && state.data.conditions.anaphylaxis.symptoms_experienced.includes('hives')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"anaphylaxis\" data-field-key=\"symptoms_experienced\"><span>Generalized hives<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-anaphylaxis_symptoms_experienced-breathing_difficulty\" name=\"anaphylaxis_symptoms_experienced[]\" value=\"breathing_difficulty\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-anaphylaxis_symptoms_experienced-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.anaphylaxis.symptoms_experienced && state.data.conditions.anaphylaxis.symptoms_experienced.includes('breathing_difficulty')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"anaphylaxis\" data-field-key=\"symptoms_experienced\"><span>Breathing difficulty<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-anaphylaxis_symptoms_experienced-dizziness\" name=\"anaphylaxis_symptoms_experienced[]\" value=\"dizziness\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-anaphylaxis_symptoms_experienced-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.anaphylaxis.symptoms_experienced && state.data.conditions.anaphylaxis.symptoms_experienced.includes('dizziness')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"anaphylaxis\" data-field-key=\"symptoms_experienced\"><span>Dizziness or headache<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-anaphylaxis_symptoms_experienced-pale_clammy\" name=\"anaphylaxis_symptoms_experienced[]\" value=\"pale_clammy\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-anaphylaxis_symptoms_experienced-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.anaphylaxis.symptoms_experienced && state.data.conditions.anaphylaxis.symptoms_experienced.includes('pale_clammy')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"anaphylaxis\" data-field-key=\"symptoms_experienced\"><span>Pale and\/or clammy<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-anaphylaxis_symptoms_experienced-nausea\" name=\"anaphylaxis_symptoms_experienced[]\" value=\"nausea\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-anaphylaxis_symptoms_experienced-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.anaphylaxis.symptoms_experienced && state.data.conditions.anaphylaxis.symptoms_experienced.includes('nausea')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"anaphylaxis\" data-field-key=\"symptoms_experienced\"><span>Nausea<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-anaphylaxis_symptoms_experienced-abdominal\" name=\"anaphylaxis_symptoms_experienced[]\" value=\"abdominal\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-anaphylaxis_symptoms_experienced-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.anaphylaxis.symptoms_experienced && state.data.conditions.anaphylaxis.symptoms_experienced.includes('abdominal')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"anaphylaxis\" data-field-key=\"symptoms_experienced\"><span>Abdominal cramps\/diarrhea<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-anaphylaxis_symptoms_experienced-agitation\" name=\"anaphylaxis_symptoms_experienced[]\" value=\"agitation\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-anaphylaxis_symptoms_experienced-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.anaphylaxis.symptoms_experienced && state.data.conditions.anaphylaxis.symptoms_experienced.includes('agitation')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"anaphylaxis\" data-field-key=\"symptoms_experienced\"><span>Agitation or skin flushing<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-anaphylaxis_symptoms_experienced-convulsions\" name=\"anaphylaxis_symptoms_experienced[]\" value=\"convulsions\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-anaphylaxis_symptoms_experienced-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.anaphylaxis.symptoms_experienced && state.data.conditions.anaphylaxis.symptoms_experienced.includes('convulsions')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"anaphylaxis\" data-field-key=\"symptoms_experienced\"><span>Convulsions<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-anaphylaxis_symptoms_experienced-itching\" name=\"anaphylaxis_symptoms_experienced[]\" value=\"itching\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-anaphylaxis_symptoms_experienced-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.anaphylaxis.symptoms_experienced && state.data.conditions.anaphylaxis.symptoms_experienced.includes('itching')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"anaphylaxis\" data-field-key=\"symptoms_experienced\"><span>Severe itching<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-anaphylaxis_symptoms_experienced-unconsciousness\" name=\"anaphylaxis_symptoms_experienced[]\" value=\"unconsciousness\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-anaphylaxis_symptoms_experienced-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.anaphylaxis.symptoms_experienced && state.data.conditions.anaphylaxis.symptoms_experienced.includes('unconsciousness')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"anaphylaxis\" data-field-key=\"symptoms_experienced\"><span>Unconsciousness<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-anaphylaxis_symptoms_experienced-throbbing\" name=\"anaphylaxis_symptoms_experienced[]\" value=\"throbbing\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-anaphylaxis_symptoms_experienced-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.anaphylaxis.symptoms_experienced && state.data.conditions.anaphylaxis.symptoms_experienced.includes('throbbing')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"anaphylaxis\" data-field-key=\"symptoms_experienced\"><span>Throbbing heartbeat or throbbing in ears<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-anaphylaxis_symptoms_experienced-other\" name=\"anaphylaxis_symptoms_experienced[]\" value=\"other\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-anaphylaxis_symptoms_experienced-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.anaphylaxis.symptoms_experienced && state.data.conditions.anaphylaxis.symptoms_experienced.includes('other')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"anaphylaxis\" data-field-key=\"symptoms_experienced\"><span>Other<\/span><\/label><\/div><div id=\"health-history-form-1-anaphylaxis_symptoms_experienced-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Which of the following symptoms has your child experienced? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-anaphylaxis_other_symptoms_detail\" class=\"block mb-2 font-medium\">6a. Please specify other symptoms<\/label><input aria-invalid=\"false\" value=\"\" type=\"text\" id=\"health-history-form-1-anaphylaxis_other_symptoms_detail\" name=\"anaphylaxis_other_symptoms_detail\" class=\"w-full input\" aria-describedby=\"health-history-form-1-anaphylaxis_other_symptoms_detail-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.anaphylaxis.other_symptoms_detail\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"anaphylaxis\" data-field-key=\"other_symptoms_detail\"><div id=\"health-history-form-1-anaphylaxis_other_symptoms_detail-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Please specify other symptoms is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-anaphylaxis_reaction_treatment\" class=\"block mb-2 font-medium\">7. Please describe the care\/treatment\/medications you provide during a reaction<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-anaphylaxis_reaction_treatment\" name=\"anaphylaxis_reaction_treatment\" class=\"w-full textarea textarea-bordered\" rows=\"4\" aria-describedby=\"health-history-form-1-anaphylaxis_reaction_treatment-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.anaphylaxis.reaction_treatment\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"anaphylaxis\" data-field-key=\"reaction_treatment\"><\/textarea><div id=\"health-history-form-1-anaphylaxis_reaction_treatment-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Please describe the care\/treatment\/medications you provide during a reaction is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">8. Has your physician prescribed an EpiPen or other medication to be kept at school? <br \/><span class='text-sm'>(If Yes, please also complete the '<a class=\"font-semibold text-blue-900 underline hover:text-gray-500\"  href='https:\/\/drive.google.com\/file\/d\/0B44Boq3d-4RbQlpqVFR5ZjFzazg\/view?usp=sharing&amp;resourcekey=0-UPKGerwPOJ8o5_4weKB2_g' target='_blank'>Parent\/Guardian and authorized health care provider request for medication<\/a>' form)<\/span><\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-anaphylaxis_epipen_at_school-yes\" name=\"anaphylaxis_epipen_at_school\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-anaphylaxis_epipen_at_school-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.anaphylaxis.epipen_at_school === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"anaphylaxis\" data-field-key=\"epipen_at_school\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-anaphylaxis_epipen_at_school-no\" name=\"anaphylaxis_epipen_at_school\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-anaphylaxis_epipen_at_school-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.anaphylaxis.epipen_at_school === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"anaphylaxis\" data-field-key=\"epipen_at_school\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-anaphylaxis_epipen_at_school-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Has your physician prescribed an EpiPen or other medication to be kept at school? <br \/><span class='text-sm'>(If Yes, please also complete the '<a class=\"font-semibold text-blue-900 underline hover:text-gray-500\"  href='https:\/\/drive.google.com\/file\/d\/0B44Boq3d-4RbQlpqVFR5ZjFzazg\/view?usp=sharing&amp;resourcekey=0-UPKGerwPOJ8o5_4weKB2_g' target='_blank'>Parent\/Guardian and authorized health care provider request for medication<\/a>' form)<\/span> is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">9. Has your physician prescribed an EpiPen or other medication to be kept at home?<\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-anaphylaxis_epipen_at_home-yes\" name=\"anaphylaxis_epipen_at_home\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-anaphylaxis_epipen_at_home-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.anaphylaxis.epipen_at_home === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"anaphylaxis\" data-field-key=\"epipen_at_home\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-anaphylaxis_epipen_at_home-no\" name=\"anaphylaxis_epipen_at_home\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-anaphylaxis_epipen_at_home-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.anaphylaxis.epipen_at_home === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"anaphylaxis\" data-field-key=\"epipen_at_home\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-anaphylaxis_epipen_at_home-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Has your physician prescribed an EpiPen or other medication to be kept at home? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">10. Any specific locations or activities at school that should be restricted due to allergy risk?<\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-anaphylaxis_has_restrictions-yes\" name=\"anaphylaxis_has_restrictions\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-anaphylaxis_has_restrictions-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.anaphylaxis.has_restrictions === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"anaphylaxis\" data-field-key=\"has_restrictions\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-anaphylaxis_has_restrictions-no\" name=\"anaphylaxis_has_restrictions\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-anaphylaxis_has_restrictions-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.anaphylaxis.has_restrictions === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"anaphylaxis\" data-field-key=\"has_restrictions\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-anaphylaxis_has_restrictions-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Any specific locations or activities at school that should be restricted due to allergy risk? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-anaphylaxis_restriction_details\" class=\"block mb-2 font-medium\">10a. If yes, please describe<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-anaphylaxis_restriction_details\" name=\"anaphylaxis_restriction_details\" class=\"w-full textarea textarea-bordered\" rows=\"3\" aria-describedby=\"health-history-form-1-anaphylaxis_restriction_details-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.anaphylaxis.restriction_details\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"anaphylaxis\" data-field-key=\"restriction_details\"><\/textarea><div id=\"health-history-form-1-anaphylaxis_restriction_details-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">If yes, please describe is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">11. Any other information about the student's allergic condition that the school staff should be aware of?<\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-anaphylaxis_additional_info_needed-yes\" name=\"anaphylaxis_additional_info_needed\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-anaphylaxis_additional_info_needed-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.anaphylaxis.additional_info_needed === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"anaphylaxis\" data-field-key=\"additional_info_needed\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-anaphylaxis_additional_info_needed-no\" name=\"anaphylaxis_additional_info_needed\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-anaphylaxis_additional_info_needed-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.anaphylaxis.additional_info_needed === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"anaphylaxis\" data-field-key=\"additional_info_needed\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-anaphylaxis_additional_info_needed-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Any other information about the student's allergic condition that the school staff should be aware of? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-anaphylaxis_comments_or_additional_info\" class=\"block mb-2 font-medium\">11a. Comments or Additional Information<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-anaphylaxis_comments_or_additional_info\" name=\"anaphylaxis_comments_or_additional_info\" class=\"w-full textarea textarea-bordered\" rows=\"3\" placeholder=\"Enter any other information that the school staff should be aware of.\" aria-describedby=\"health-history-form-1-anaphylaxis_comments_or_additional_info-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.anaphylaxis.comments_or_additional_info\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"anaphylaxis\" data-field-key=\"comments_or_additional_info\"><\/textarea><div id=\"health-history-form-1-anaphylaxis_comments_or_additional_info-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Comments or Additional Information is required<\/div><\/div>\n    <\/fieldset>\n    \r\n    <!-- Asthma -->\r\n        <fieldset aria-hidden=\"true\" disabled hidden\n        id=\"health-history-form-1-condition-asthma\"\n        class=\"block md:grid md:grid-cols-12 md:items-center gap-x-5 gap-y-3 bg-base-300\/50 p-4 rounded-lg mb-6\"\n        data-wp-context='{\"conditionKey\": \"asthma\"}'\n        data-wp-bind--hidden=\"!state.data.conditions.asthma.enabled\"\n        data-wp-bind--disabled=\"!state.data.conditions.asthma.enabled\"\n        data-wp-bind--aria-hidden=\"!state.data.conditions.asthma.enabled\"\n    >\n        <legend class=\"sticky top-5 z-50 fieldset-legend bg-info text-info-content px-4 py-1 text-xs rounded-full\">\n            Asthma Details        <\/legend>\n\n        <div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">1. Has your child's asthma been diagnosed by a doctor?<\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-asthma_diagnosed_by_doctor-yes\" name=\"asthma_diagnosed_by_doctor\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_diagnosed_by_doctor-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.diagnosed_by_doctor === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"asthma\" data-field-key=\"diagnosed_by_doctor\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-asthma_diagnosed_by_doctor-no\" name=\"asthma_diagnosed_by_doctor\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_diagnosed_by_doctor-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.diagnosed_by_doctor === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"asthma\" data-field-key=\"diagnosed_by_doctor\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-asthma_diagnosed_by_doctor-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Has your child's asthma been diagnosed by a doctor? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">2. Is your child currently under a doctor's care for asthma?<\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-asthma_currently_under_care-yes\" name=\"asthma_currently_under_care\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_currently_under_care-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.currently_under_care === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"asthma\" data-field-key=\"currently_under_care\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-asthma_currently_under_care-no\" name=\"asthma_currently_under_care\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_currently_under_care-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.currently_under_care === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"asthma\" data-field-key=\"currently_under_care\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-asthma_currently_under_care-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Is your child currently under a doctor's care for asthma? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-asthma_age_diagnosed\" class=\"block mb-2 font-medium\">3. Age when asthma was first diagnosed:<\/label><input aria-invalid=\"false\" value=\"\" type=\"number\" id=\"health-history-form-1-asthma_age_diagnosed\" name=\"asthma_age_diagnosed\" class=\"w-full input\" aria-describedby=\"health-history-form-1-asthma_age_diagnosed-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.asthma.age_diagnosed\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"asthma\" data-field-key=\"age_diagnosed\"><div id=\"health-history-form-1-asthma_age_diagnosed-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Age when asthma was first diagnosed: is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-3 font-medium\">4. Which are your child's triggers?<\/legend><div class=\"grid grid-cols-1 gap-2 sm:grid-cols-2\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-asthma_triggers-grass\" name=\"asthma_triggers[]\" value=\"grass\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_triggers-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.triggers && state.data.conditions.asthma.triggers.includes('grass')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"asthma\" data-field-key=\"triggers\"><span>Grass<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-asthma_triggers-respiratory_infections\" name=\"asthma_triggers[]\" value=\"respiratory_infections\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_triggers-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.triggers && state.data.conditions.asthma.triggers.includes('respiratory_infections')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"asthma\" data-field-key=\"triggers\"><span>Respiratory infections<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-asthma_triggers-pollens\" name=\"asthma_triggers[]\" value=\"pollens\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_triggers-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.triggers && state.data.conditions.asthma.triggers.includes('pollens')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"asthma\" data-field-key=\"triggers\"><span>Pollens<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-asthma_triggers-strong_emotions\" name=\"asthma_triggers[]\" value=\"strong_emotions\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_triggers-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.triggers && state.data.conditions.asthma.triggers.includes('strong_emotions')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"asthma\" data-field-key=\"triggers\"><span>Strong Emotions<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-asthma_triggers-mold\" name=\"asthma_triggers[]\" value=\"mold\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_triggers-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.triggers && state.data.conditions.asthma.triggers.includes('mold')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"asthma\" data-field-key=\"triggers\"><span>Mold<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-asthma_triggers-physical_activity\" name=\"asthma_triggers[]\" value=\"physical_activity\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_triggers-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.triggers && state.data.conditions.asthma.triggers.includes('physical_activity')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"asthma\" data-field-key=\"triggers\"><span>Physical activity<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-asthma_triggers-house_dust_mites\" name=\"asthma_triggers[]\" value=\"house_dust_mites\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_triggers-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.triggers && state.data.conditions.asthma.triggers.includes('house_dust_mites')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"asthma\" data-field-key=\"triggers\"><span>House dust mites<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-asthma_triggers-weather_conditions\" name=\"asthma_triggers[]\" value=\"weather_conditions\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_triggers-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.triggers && state.data.conditions.asthma.triggers.includes('weather_conditions')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"asthma\" data-field-key=\"triggers\"><span>Weather conditions<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-asthma_triggers-animals\" name=\"asthma_triggers[]\" value=\"animals\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_triggers-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.triggers && state.data.conditions.asthma.triggers.includes('animals')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"asthma\" data-field-key=\"triggers\"><span>Animals<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-asthma_triggers-foods\" name=\"asthma_triggers[]\" value=\"foods\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_triggers-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.triggers && state.data.conditions.asthma.triggers.includes('foods')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"asthma\" data-field-key=\"triggers\"><span>Foods<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-asthma_triggers-pet_dander\" name=\"asthma_triggers[]\" value=\"pet_dander\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_triggers-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.triggers && state.data.conditions.asthma.triggers.includes('pet_dander')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"asthma\" data-field-key=\"triggers\"><span>Pet Dander<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-asthma_triggers-others\" name=\"asthma_triggers[]\" value=\"others\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_triggers-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.triggers && state.data.conditions.asthma.triggers.includes('others')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"asthma\" data-field-key=\"triggers\"><span>Others<\/span><\/label><\/div><div id=\"health-history-form-1-asthma_triggers-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Which are your child's triggers? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">5. Please describe your child's asthma:<\/legend><div class=\"space-y-2\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-asthma_asthma_type-mild_intermittent\" name=\"asthma_asthma_type\" value=\"mild_intermittent\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_asthma_type-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.asthma_type === 'mild_intermittent'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"asthma\" data-field-key=\"asthma_type\"><span class=\"label-text\">Mild Intermittent<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-asthma_asthma_type-mild_persistent\" name=\"asthma_asthma_type\" value=\"mild_persistent\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_asthma_type-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.asthma_type === 'mild_persistent'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"asthma\" data-field-key=\"asthma_type\"><span class=\"label-text\">Mild Persistent<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-asthma_asthma_type-moderate_persistent\" name=\"asthma_asthma_type\" value=\"moderate_persistent\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_asthma_type-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.asthma_type === 'moderate_persistent'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"asthma\" data-field-key=\"asthma_type\"><span class=\"label-text\">Moderate Persistent<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-asthma_asthma_type-severe_persistent\" name=\"asthma_asthma_type\" value=\"severe_persistent\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_asthma_type-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.asthma_type === 'severe_persistent'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"asthma\" data-field-key=\"asthma_type\"><span class=\"label-text\">Severe Persistent<\/span><\/label><\/div><div id=\"health-history-form-1-asthma_asthma_type-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Please describe your child's asthma: is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">6. How often does your child experience cough, shortness of breath or wheezing?<\/legend><div class=\"space-y-2\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-asthma_symptom_frequency-seldom\" name=\"asthma_symptom_frequency\" value=\"seldom\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_symptom_frequency-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.symptom_frequency === 'seldom'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"asthma\" data-field-key=\"symptom_frequency\"><span class=\"label-text\">Seldom<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-asthma_symptom_frequency-1-2_per_month\" name=\"asthma_symptom_frequency\" value=\"1-2_per_month\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_symptom_frequency-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.symptom_frequency === '1-2_per_month'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"asthma\" data-field-key=\"symptom_frequency\"><span class=\"label-text\">1-2 times per month<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-asthma_symptom_frequency-1-2_per_week\" name=\"asthma_symptom_frequency\" value=\"1-2_per_week\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_symptom_frequency-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.symptom_frequency === '1-2_per_week'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"asthma\" data-field-key=\"symptom_frequency\"><span class=\"label-text\">1-2 times per week<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-asthma_symptom_frequency-3-5_per_week\" name=\"asthma_symptom_frequency\" value=\"3-5_per_week\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_symptom_frequency-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.symptom_frequency === '3-5_per_week'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"asthma\" data-field-key=\"symptom_frequency\"><span class=\"label-text\">3-5 times per week<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-asthma_symptom_frequency-daily\" name=\"asthma_symptom_frequency\" value=\"daily\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_symptom_frequency-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.symptom_frequency === 'daily'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"asthma\" data-field-key=\"symptom_frequency\"><span class=\"label-text\">Daily<\/span><\/label><\/div><div id=\"health-history-form-1-asthma_symptom_frequency-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">How often does your child experience cough, shortness of breath or wheezing? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">7. How often does your child wake at night coughing or wheezing?<\/legend><div class=\"space-y-2\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-asthma_night_symptoms-never\" name=\"asthma_night_symptoms\" value=\"never\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_night_symptoms-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.night_symptoms === 'never'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"asthma\" data-field-key=\"night_symptoms\"><span class=\"label-text\">Never<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-asthma_night_symptoms-1-2_per_month\" name=\"asthma_night_symptoms\" value=\"1-2_per_month\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_night_symptoms-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.night_symptoms === '1-2_per_month'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"asthma\" data-field-key=\"night_symptoms\"><span class=\"label-text\">1-2 times per month<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-asthma_night_symptoms-1-2_per_week\" name=\"asthma_night_symptoms\" value=\"1-2_per_week\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_night_symptoms-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.night_symptoms === '1-2_per_week'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"asthma\" data-field-key=\"night_symptoms\"><span class=\"label-text\">1-2 times per week<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-asthma_night_symptoms-3-5_per_week\" name=\"asthma_night_symptoms\" value=\"3-5_per_week\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_night_symptoms-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.night_symptoms === '3-5_per_week'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"asthma\" data-field-key=\"night_symptoms\"><span class=\"label-text\">3-5 times per week<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-asthma_night_symptoms-daily\" name=\"asthma_night_symptoms\" value=\"daily\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_night_symptoms-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.night_symptoms === 'daily'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"asthma\" data-field-key=\"night_symptoms\"><span class=\"label-text\">Daily<\/span><\/label><\/div><div id=\"health-history-form-1-asthma_night_symptoms-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">How often does your child wake at night coughing or wheezing? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">8. How often does your child miss school due to asthma?<\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-asthma_miss_school-never\" name=\"asthma_miss_school\" value=\"never\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_miss_school-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.miss_school === 'never'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"asthma\" data-field-key=\"miss_school\"><span class=\"label-text\">Never<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-asthma_miss_school-occasionally\" name=\"asthma_miss_school\" value=\"occasionally\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_miss_school-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.miss_school === 'occasionally'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"asthma\" data-field-key=\"miss_school\"><span class=\"label-text\">Occasionally<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-asthma_miss_school-often\" name=\"asthma_miss_school\" value=\"often\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_miss_school-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.miss_school === 'often'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"asthma\" data-field-key=\"miss_school\"><span class=\"label-text\">Often<\/span><\/label><\/div><div id=\"health-history-form-1-asthma_miss_school-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">How often does your child miss school due to asthma? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">9. Has your doctor recommended any physical restrictions? <br \/><span class='text-sm'>(If yes, please complete the <a class=\"font-semibold text-blue-900 underline hover:text-gray-500\"  href='https:\/\/drive.google.com\/file\/d\/1HAFy7t8LJe_tjFf5GoooaYBmeWyo-sz9\/view?usp=sharing' target='_blank'>Medical Clearance for School Participation<\/a> form.)<\/span><\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-asthma_physical_restrictions_recommended-yes\" name=\"asthma_physical_restrictions_recommended\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_physical_restrictions_recommended-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.physical_restrictions_recommended === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"asthma\" data-field-key=\"physical_restrictions_recommended\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-asthma_physical_restrictions_recommended-no\" name=\"asthma_physical_restrictions_recommended\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_physical_restrictions_recommended-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.physical_restrictions_recommended === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"asthma\" data-field-key=\"physical_restrictions_recommended\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-asthma_physical_restrictions_recommended-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Has your doctor recommended any physical restrictions? <br \/><span class='text-sm'>(If yes, please complete the <a class=\"font-semibold text-blue-900 underline hover:text-gray-500\"  href='https:\/\/drive.google.com\/file\/d\/1HAFy7t8LJe_tjFf5GoooaYBmeWyo-sz9\/view?usp=sharing' target='_blank'>Medical Clearance for School Participation<\/a> form.)<\/span> is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-asthma_physical_restrictions_explanation\" class=\"block mb-2 font-medium\">9a. Explain physical restrictions<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-asthma_physical_restrictions_explanation\" name=\"asthma_physical_restrictions_explanation\" class=\"w-full textarea textarea-bordered\" rows=\"3\" aria-describedby=\"health-history-form-1-asthma_physical_restrictions_explanation-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.asthma.physical_restrictions_explanation\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"asthma\" data-field-key=\"physical_restrictions_explanation\"><\/textarea><div id=\"health-history-form-1-asthma_physical_restrictions_explanation-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Explain physical restrictions is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-asthma_visits_last_year\" class=\"block mb-2 font-medium\">10. Number of visits to doctor's office for asthma in the past year:<\/label><input aria-invalid=\"false\" value=\"\" type=\"number\" id=\"health-history-form-1-asthma_visits_last_year\" name=\"asthma_visits_last_year\" class=\"w-full input\" aria-describedby=\"health-history-form-1-asthma_visits_last_year-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.asthma.visits_last_year\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"asthma\" data-field-key=\"visits_last_year\"><div id=\"health-history-form-1-asthma_visits_last_year-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Number of visits to doctor's office for asthma in the past year: is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-asthma_hospitalizations\" class=\"block mb-2 font-medium\">11. How many times has your child been hospitalized for asthma?<\/label><input aria-invalid=\"false\" value=\"\" type=\"number\" id=\"health-history-form-1-asthma_hospitalizations\" name=\"asthma_hospitalizations\" class=\"w-full input\" aria-describedby=\"health-history-form-1-asthma_hospitalizations-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.asthma.hospitalizations\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"asthma\" data-field-key=\"hospitalizations\"><div id=\"health-history-form-1-asthma_hospitalizations-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">How many times has your child been hospitalized for asthma? is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-asthma_emergency_visits\" class=\"block mb-2 font-medium\">11a. How many times has your child visited the emergency room for asthma?<\/label><input aria-invalid=\"false\" value=\"\" type=\"number\" id=\"health-history-form-1-asthma_emergency_visits\" name=\"asthma_emergency_visits\" class=\"w-full input\" aria-describedby=\"health-history-form-1-asthma_emergency_visits-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.asthma.emergency_visits\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"asthma\" data-field-key=\"emergency_visits\"><div id=\"health-history-form-1-asthma_emergency_visits-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">How many times has your child visited the emergency room for asthma? is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">12. Does your child receive nebulizer?<\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-asthma_nebulizer_at_home-yes\" name=\"asthma_nebulizer_at_home\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_nebulizer_at_home-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.nebulizer_at_home === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"asthma\" data-field-key=\"nebulizer_at_home\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-asthma_nebulizer_at_home-no\" name=\"asthma_nebulizer_at_home\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_nebulizer_at_home-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.nebulizer_at_home === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"asthma\" data-field-key=\"nebulizer_at_home\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-asthma_nebulizer_at_home-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Does your child receive nebulizer? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">13. Is your child taking medication for asthma? <br \/><span class='text-sm'>(If Yes, please also complete the '<a class=\"font-semibold text-blue-900 underline hover:text-gray-500\"  href='https:\/\/drive.google.com\/file\/d\/0B44Boq3d-4RbQlpqVFR5ZjFzazg\/view?usp=sharing&amp;resourcekey=0-UPKGerwPOJ8o5_4weKB2_g' target='_blank'>Parent\/Guardian and authorized health care provider request for medication<\/a>' form)<\/span><\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-asthma_taking_medication-yes\" name=\"asthma_taking_medication\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_taking_medication-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.taking_medication === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"asthma\" data-field-key=\"taking_medication\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-asthma_taking_medication-no\" name=\"asthma_taking_medication\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-asthma_taking_medication-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.asthma.taking_medication === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"asthma\" data-field-key=\"taking_medication\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-asthma_taking_medication-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Is your child taking medication for asthma? <br \/><span class='text-sm'>(If Yes, please also complete the '<a class=\"font-semibold text-blue-900 underline hover:text-gray-500\"  href='https:\/\/drive.google.com\/file\/d\/0B44Boq3d-4RbQlpqVFR5ZjFzazg\/view?usp=sharing&amp;resourcekey=0-UPKGerwPOJ8o5_4weKB2_g' target='_blank'>Parent\/Guardian and authorized health care provider request for medication<\/a>' form)<\/span> is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-asthma_medication_name\" class=\"block mb-2 font-medium\">13a. Medication(s):<\/label><input aria-invalid=\"false\" value=\"\" type=\"text\" id=\"health-history-form-1-asthma_medication_name\" name=\"asthma_medication_name\" class=\"w-full input\" aria-describedby=\"health-history-form-1-asthma_medication_name-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.asthma.medication_name\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"asthma\" data-field-key=\"medication_name\"><div id=\"health-history-form-1-asthma_medication_name-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Medication(s): is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-asthma_comments_or_additional_info\" class=\"block mb-2 font-medium\">14. Comments or Additional Information<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-asthma_comments_or_additional_info\" name=\"asthma_comments_or_additional_info\" class=\"w-full textarea textarea-bordered\" rows=\"3\" placeholder=\"Enter any other information that the school staff should be aware of.\" aria-describedby=\"health-history-form-1-asthma_comments_or_additional_info-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.asthma.comments_or_additional_info\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"asthma\" data-field-key=\"comments_or_additional_info\"><\/textarea><div id=\"health-history-form-1-asthma_comments_or_additional_info-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Comments or Additional Information is required<\/div><\/div>\n    <\/fieldset>\n      \r\n    <!-- Diabetes Fields -->\r\n        <fieldset aria-hidden=\"true\" disabled hidden\n        id=\"health-history-form-1-condition-diabetes\"\n        class=\"block md:grid md:grid-cols-12 md:items-center gap-x-5 gap-y-3 bg-base-300\/50 p-4 rounded-lg mb-6\"\n        data-wp-context='{\"conditionKey\": \"diabetes\"}'\n        data-wp-bind--hidden=\"!state.data.conditions.diabetes.enabled\"\n        data-wp-bind--disabled=\"!state.data.conditions.diabetes.enabled\"\n        data-wp-bind--aria-hidden=\"!state.data.conditions.diabetes.enabled\"\n    >\n        <legend class=\"sticky top-5 z-50 fieldset-legend bg-info text-info-content px-4 py-1 text-xs rounded-full\">\n            Diabetes Details        <\/legend>\n\n        <div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-diabetes_age_diagnosed\" class=\"block mb-2 font-medium\">1. Age Diabetes Diagnosed:<\/label><input aria-invalid=\"false\" value=\"\" type=\"number\" id=\"health-history-form-1-diabetes_age_diagnosed\" name=\"diabetes_age_diagnosed\" class=\"w-full input\" aria-describedby=\"health-history-form-1-diabetes_age_diagnosed-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.diabetes.age_diagnosed\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"diabetes\" data-field-key=\"age_diagnosed\"><div id=\"health-history-form-1-diabetes_age_diagnosed-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Age Diabetes Diagnosed: is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-diabetes_diabetes_type\" class=\"block mb-2 font-medium\">2. What Type of Diabetes:<\/label><input aria-invalid=\"false\" value=\"\" type=\"text\" id=\"health-history-form-1-diabetes_diabetes_type\" name=\"diabetes_diabetes_type\" class=\"w-full input\" placeholder=\"e.g., Type 1, Type 2\" aria-describedby=\"health-history-form-1-diabetes_diabetes_type-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.diabetes.diabetes_type\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"diabetes\" data-field-key=\"diabetes_type\"><div id=\"health-history-form-1-diabetes_diabetes_type-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">What Type of Diabetes: is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-diabetes_monitoring_method\" class=\"block mb-2 font-medium\">3. How is your chid's blood sugar monitored? <\/label><input aria-invalid=\"false\" value=\"\" type=\"text\" id=\"health-history-form-1-diabetes_monitoring_method\" name=\"diabetes_monitoring_method\" class=\"w-full input\" placeholder=\"e.g., Glucometer (finger stick), Continuous Glucose Monitoring device (Dexacom), etc.\" aria-describedby=\"health-history-form-1-diabetes_monitoring_method-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.diabetes.monitoring_method\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"diabetes\" data-field-key=\"monitoring_method\"><div id=\"health-history-form-1-diabetes_monitoring_method-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">How is your chid's blood sugar monitored?  is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">4. Does your child take insulin?<\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-diabetes_does_child_take_insulin-yes\" name=\"diabetes_does_child_take_insulin\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-diabetes_does_child_take_insulin-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.diabetes.does_child_take_insulin === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"diabetes\" data-field-key=\"does_child_take_insulin\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-diabetes_does_child_take_insulin-no\" name=\"diabetes_does_child_take_insulin\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-diabetes_does_child_take_insulin-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.diabetes.does_child_take_insulin === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"diabetes\" data-field-key=\"does_child_take_insulin\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-diabetes_does_child_take_insulin-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Does your child take insulin? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-diabetes_insulin_delivery_method\" class=\"block mb-2 font-medium\">4a. If yes, what is the method of delivery?<\/label><input aria-invalid=\"false\" value=\"\" type=\"text\" id=\"health-history-form-1-diabetes_insulin_delivery_method\" name=\"diabetes_insulin_delivery_method\" class=\"w-full input\" placeholder=\"e.g., injections, pen, pump (Omnipod), etc.\" aria-describedby=\"health-history-form-1-diabetes_insulin_delivery_method-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.diabetes.insulin_delivery_method\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"diabetes\" data-field-key=\"insulin_delivery_method\"><div id=\"health-history-form-1-diabetes_insulin_delivery_method-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">If yes, what is the method of delivery? is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-diabetes_low_sugar_symptoms\" class=\"block mb-2 font-medium\">5. What does your child say\/do when their sugar level is low?<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-diabetes_low_sugar_symptoms\" name=\"diabetes_low_sugar_symptoms\" class=\"w-full textarea textarea-bordered\" rows=\"3\" aria-describedby=\"health-history-form-1-diabetes_low_sugar_symptoms-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.diabetes.low_sugar_symptoms\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"diabetes\" data-field-key=\"low_sugar_symptoms\"><\/textarea><div id=\"health-history-form-1-diabetes_low_sugar_symptoms-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">What does your child say\/do when their sugar level is low? is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-diabetes_high_sugar_symptoms\" class=\"block mb-2 font-medium\">6. What does your child say\/do when their sugar level is high?<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-diabetes_high_sugar_symptoms\" name=\"diabetes_high_sugar_symptoms\" class=\"w-full textarea textarea-bordered\" rows=\"3\" aria-describedby=\"health-history-form-1-diabetes_high_sugar_symptoms-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.diabetes.high_sugar_symptoms\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"diabetes\" data-field-key=\"high_sugar_symptoms\"><\/textarea><div id=\"health-history-form-1-diabetes_high_sugar_symptoms-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">What does your child say\/do when their sugar level is high? is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-diabetes_emergency_medication\" class=\"block mb-2 font-medium\">7. Does your child have emergency medications? If so, please list:<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-diabetes_emergency_medication\" name=\"diabetes_emergency_medication\" class=\"w-full textarea textarea-bordered\" rows=\"3\" placeholder=\"e.g., Glucagon, Bagsimi, etc.\" aria-describedby=\"health-history-form-1-diabetes_emergency_medication-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.diabetes.emergency_medication\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"diabetes\" data-field-key=\"emergency_medication\"><\/textarea><div id=\"health-history-form-1-diabetes_emergency_medication-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Does your child have emergency medications? If so, please list: is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">8. Does your child have a special diet? <br \/> <span class='text-sm'>(If yes, please also complete the '<a class=\"font-semibold text-blue-900 underline hover:text-gray-500\"  href='https:\/\/drive.google.com\/file\/d\/1duFLA0uvNddNureO94HA225Um9FcfYHJ\/view?usp=sharing' target='_blank'>Medical Statement to Request Special Meal Accommodations<\/a>' form)<\/span><\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-diabetes_spcecial_diet-yes\" name=\"diabetes_spcecial_diet\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-diabetes_spcecial_diet-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.diabetes.spcecial_diet === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"diabetes\" data-field-key=\"spcecial_diet\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-diabetes_spcecial_diet-no\" name=\"diabetes_spcecial_diet\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-diabetes_spcecial_diet-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.diabetes.spcecial_diet === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"diabetes\" data-field-key=\"spcecial_diet\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-diabetes_spcecial_diet-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Does your child have a special diet? <br \/> <span class='text-sm'>(If yes, please also complete the '<a class=\"font-semibold text-blue-900 underline hover:text-gray-500\"  href='https:\/\/drive.google.com\/file\/d\/1duFLA0uvNddNureO94HA225Um9FcfYHJ\/view?usp=sharing' target='_blank'>Medical Statement to Request Special Meal Accommodations<\/a>' form)<\/span> is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-diabetes_comments_or_additional_info\" class=\"block mb-2 font-medium\">9. Comments or Additional Information<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-diabetes_comments_or_additional_info\" name=\"diabetes_comments_or_additional_info\" class=\"w-full textarea textarea-bordered\" rows=\"3\" placeholder=\"Enter any other information that the school staff should be aware of.\" aria-describedby=\"health-history-form-1-diabetes_comments_or_additional_info-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.diabetes.comments_or_additional_info\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"diabetes\" data-field-key=\"comments_or_additional_info\"><\/textarea><div id=\"health-history-form-1-diabetes_comments_or_additional_info-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Comments or Additional Information is required<\/div><\/div>\n    <\/fieldset>\n    \r\n    <!-- Heart Condition -->       \r\n        <fieldset aria-hidden=\"true\" disabled hidden\n        id=\"health-history-form-1-condition-heart_condition\"\n        class=\"block md:grid md:grid-cols-12 md:items-center gap-x-5 gap-y-3 bg-base-300\/50 p-4 rounded-lg mb-6\"\n        data-wp-context='{\"conditionKey\": \"heart_condition\"}'\n        data-wp-bind--hidden=\"!state.data.conditions.heart_condition.enabled\"\n        data-wp-bind--disabled=\"!state.data.conditions.heart_condition.enabled\"\n        data-wp-bind--aria-hidden=\"!state.data.conditions.heart_condition.enabled\"\n    >\n        <legend class=\"sticky top-5 z-50 fieldset-legend bg-info text-info-content px-4 py-1 text-xs rounded-full\">\n            Heart Condition Details        <\/legend>\n\n        <div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-heart_condition_age_diagnosis\" class=\"block mb-2 font-medium\">1. Age of diagnosis:<\/label><input aria-invalid=\"false\" value=\"\" type=\"number\" id=\"health-history-form-1-heart_condition_age_diagnosis\" name=\"heart_condition_age_diagnosis\" class=\"w-full input\" aria-describedby=\"health-history-form-1-heart_condition_age_diagnosis-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.heart_condition.age_diagnosis\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"heart_condition\" data-field-key=\"age_diagnosis\"><div id=\"health-history-form-1-heart_condition_age_diagnosis-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Age of diagnosis: is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">2. Is your child currently under the care of a cardiologist?<\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-heart_condition_under_cardiologist_care-yes\" name=\"heart_condition_under_cardiologist_care\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_under_cardiologist_care-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.under_cardiologist_care === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"heart_condition\" data-field-key=\"under_cardiologist_care\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-heart_condition_under_cardiologist_care-no\" name=\"heart_condition_under_cardiologist_care\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_under_cardiologist_care-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.under_cardiologist_care === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"heart_condition\" data-field-key=\"under_cardiologist_care\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-heart_condition_under_cardiologist_care-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Is your child currently under the care of a cardiologist? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-heart_condition_visit_frequency\" class=\"block mb-2 font-medium\">2a. If yes, how frequently is he\/she seen?<\/label><input aria-invalid=\"false\" value=\"\" type=\"text\" id=\"health-history-form-1-heart_condition_visit_frequency\" name=\"heart_condition_visit_frequency\" class=\"w-full input\" aria-describedby=\"health-history-form-1-heart_condition_visit_frequency-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.heart_condition.visit_frequency\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"heart_condition\" data-field-key=\"visit_frequency\"><div id=\"health-history-form-1-heart_condition_visit_frequency-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">If yes, how frequently is he\/she seen? is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-3 font-medium\">3. Type of heart condition:<\/legend><div class=\"grid grid-cols-1 gap-2 sm:grid-cols-2\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-heart_condition_condition_types-murmur\" name=\"heart_condition_condition_types[]\" value=\"murmur\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_condition_types-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.condition_types && state.data.conditions.heart_condition.condition_types.includes('murmur')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"heart_condition\" data-field-key=\"condition_types\"><span>Murmur<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-heart_condition_condition_types-arrhythmias\" name=\"heart_condition_condition_types[]\" value=\"arrhythmias\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_condition_types-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.condition_types && state.data.conditions.heart_condition.condition_types.includes('arrhythmias')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"heart_condition\" data-field-key=\"condition_types\"><span>Arrhythmias<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-heart_condition_condition_types-coarctation_aorta\" name=\"heart_condition_condition_types[]\" value=\"coarctation_aorta\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_condition_types-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.condition_types && state.data.conditions.heart_condition.condition_types.includes('coarctation_aorta')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"heart_condition\" data-field-key=\"condition_types\"><span>Coarctation of the Aorta<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-heart_condition_condition_types-atrial_septal_defect\" name=\"heart_condition_condition_types[]\" value=\"atrial_septal_defect\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_condition_types-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.condition_types && state.data.conditions.heart_condition.condition_types.includes('atrial_septal_defect')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"heart_condition\" data-field-key=\"condition_types\"><span>Atrial Septal Defect (ASD)<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-heart_condition_condition_types-aortic_valve_stenosis\" name=\"heart_condition_condition_types[]\" value=\"aortic_valve_stenosis\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_condition_types-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.condition_types && state.data.conditions.heart_condition.condition_types.includes('aortic_valve_stenosis')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"heart_condition\" data-field-key=\"condition_types\"><span>Aortic Valve Stenosis<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-heart_condition_condition_types-congestive_heart_failure\" name=\"heart_condition_condition_types[]\" value=\"congestive_heart_failure\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_condition_types-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.condition_types && state.data.conditions.heart_condition.condition_types.includes('congestive_heart_failure')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"heart_condition\" data-field-key=\"condition_types\"><span>Congestive Heart Failure<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-heart_condition_condition_types-patent_ductus_arteriosus\" name=\"heart_condition_condition_types[]\" value=\"patent_ductus_arteriosus\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_condition_types-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.condition_types && state.data.conditions.heart_condition.condition_types.includes('patent_ductus_arteriosus')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"heart_condition\" data-field-key=\"condition_types\"><span>Patent Ductus Arteriosus (PDA)<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-heart_condition_condition_types-tetralogy_of_fallot\" name=\"heart_condition_condition_types[]\" value=\"tetralogy_of_fallot\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_condition_types-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.condition_types && state.data.conditions.heart_condition.condition_types.includes('tetralogy_of_fallot')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"heart_condition\" data-field-key=\"condition_types\"><span>Tetralogy of Fallot<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-heart_condition_condition_types-transposition_great_vessels\" name=\"heart_condition_condition_types[]\" value=\"transposition_great_vessels\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_condition_types-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.condition_types && state.data.conditions.heart_condition.condition_types.includes('transposition_great_vessels')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"heart_condition\" data-field-key=\"condition_types\"><span>Transposition of the Great Vessels<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-heart_condition_condition_types-truncus_arteriosus\" name=\"heart_condition_condition_types[]\" value=\"truncus_arteriosus\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_condition_types-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.condition_types && state.data.conditions.heart_condition.condition_types.includes('truncus_arteriosus')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"heart_condition\" data-field-key=\"condition_types\"><span>Truncus Arteriosus<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-heart_condition_condition_types-ventricular_septal_defect\" name=\"heart_condition_condition_types[]\" value=\"ventricular_septal_defect\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_condition_types-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.condition_types && state.data.conditions.heart_condition.condition_types.includes('ventricular_septal_defect')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"heart_condition\" data-field-key=\"condition_types\"><span>Ventricular Septal Defect (VSD)<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-heart_condition_condition_types-other\" name=\"heart_condition_condition_types[]\" value=\"other\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_condition_types-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.condition_types && state.data.conditions.heart_condition.condition_types.includes('other')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"heart_condition\" data-field-key=\"condition_types\"><span>Other<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-heart_condition_condition_types-do_not_know\" name=\"heart_condition_condition_types[]\" value=\"do_not_know\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_condition_types-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.condition_types && state.data.conditions.heart_condition.condition_types.includes('do_not_know')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"heart_condition\" data-field-key=\"condition_types\"><span>Do not know<\/span><\/label><\/div><div id=\"health-history-form-1-heart_condition_condition_types-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Type of heart condition: is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-heart_condition_other_condition_detail\" class=\"block mb-2 font-medium\">3a. Please specify other condition:<\/label><input aria-invalid=\"false\" value=\"\" type=\"text\" id=\"health-history-form-1-heart_condition_other_condition_detail\" name=\"heart_condition_other_condition_detail\" class=\"w-full input\" aria-describedby=\"health-history-form-1-heart_condition_other_condition_detail-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.heart_condition.other_condition_detail\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"heart_condition\" data-field-key=\"other_condition_detail\"><div id=\"health-history-form-1-heart_condition_other_condition_detail-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Please specify other condition: is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-3 font-medium\">4. Does your child have any of the following symptoms?<\/legend><div class=\"grid grid-cols-1 gap-2 sm:grid-cols-2\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-heart_condition_symptoms-shortness_of_breath\" name=\"heart_condition_symptoms[]\" value=\"shortness_of_breath\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_symptoms-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.symptoms && state.data.conditions.heart_condition.symptoms.includes('shortness_of_breath')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"heart_condition\" data-field-key=\"symptoms\"><span>Shortness of Breath<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-heart_condition_symptoms-color_change\" name=\"heart_condition_symptoms[]\" value=\"color_change\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_symptoms-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.symptoms && state.data.conditions.heart_condition.symptoms.includes('color_change')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"heart_condition\" data-field-key=\"symptoms\"><span>Color Change<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-heart_condition_symptoms-chest_pain\" name=\"heart_condition_symptoms[]\" value=\"chest_pain\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_symptoms-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.symptoms && state.data.conditions.heart_condition.symptoms.includes('chest_pain')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"heart_condition\" data-field-key=\"symptoms\"><span>Chest Pain<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-heart_condition_symptoms-dizziness\" name=\"heart_condition_symptoms[]\" value=\"dizziness\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_symptoms-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.symptoms && state.data.conditions.heart_condition.symptoms.includes('dizziness')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"heart_condition\" data-field-key=\"symptoms\"><span>Dizziness<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-heart_condition_symptoms-fainting\" name=\"heart_condition_symptoms[]\" value=\"fainting\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_symptoms-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.symptoms && state.data.conditions.heart_condition.symptoms.includes('fainting')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"heart_condition\" data-field-key=\"symptoms\"><span>Fainting<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-heart_condition_symptoms-irregular_heartbeat\" name=\"heart_condition_symptoms[]\" value=\"irregular_heartbeat\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_symptoms-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.symptoms && state.data.conditions.heart_condition.symptoms.includes('irregular_heartbeat')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"heart_condition\" data-field-key=\"symptoms\"><span>Irregular heartbeat<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-heart_condition_symptoms-swelling_legs_ankles\" name=\"heart_condition_symptoms[]\" value=\"swelling_legs_ankles\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_symptoms-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.symptoms && state.data.conditions.heart_condition.symptoms.includes('swelling_legs_ankles')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"heart_condition\" data-field-key=\"symptoms\"><span>Swelling: Legs\/Ankles<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-heart_condition_symptoms-fatigue_weakness\" name=\"heart_condition_symptoms[]\" value=\"fatigue_weakness\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_symptoms-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.symptoms && state.data.conditions.heart_condition.symptoms.includes('fatigue_weakness')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"heart_condition\" data-field-key=\"symptoms\"><span>Fatigue or Weakness<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"checkbox\" id=\"health-history-form-1-heart_condition_symptoms-other\" name=\"heart_condition_symptoms[]\" value=\"other\" class=\"checkbox bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_symptoms-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--checkbox-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.symptoms && state.data.conditions.heart_condition.symptoms.includes('other')\" data-wp-on--change=\"actions.updateCheckboxGroup\" data-condition-key=\"heart_condition\" data-field-key=\"symptoms\"><span>Other<\/span><\/label><\/div><div id=\"health-history-form-1-heart_condition_symptoms-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Does your child have any of the following symptoms? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-heart_condition_other_symptoms_detail\" class=\"block mb-2 font-medium\">4a. Please specify other symptoms:<\/label><input aria-invalid=\"false\" value=\"\" type=\"text\" id=\"health-history-form-1-heart_condition_other_symptoms_detail\" name=\"heart_condition_other_symptoms_detail\" class=\"w-full input\" aria-describedby=\"health-history-form-1-heart_condition_other_symptoms_detail-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.heart_condition.other_symptoms_detail\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"heart_condition\" data-field-key=\"other_symptoms_detail\"><div id=\"health-history-form-1-heart_condition_other_symptoms_detail-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Please specify other symptoms: is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">5. Has your child ever had surgery?<\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-heart_condition_had_surgery-yes\" name=\"heart_condition_had_surgery\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_had_surgery-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.had_surgery === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"heart_condition\" data-field-key=\"had_surgery\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-heart_condition_had_surgery-no\" name=\"heart_condition_had_surgery\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_had_surgery-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.had_surgery === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"heart_condition\" data-field-key=\"had_surgery\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-heart_condition_had_surgery-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Has your child ever had surgery? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-heart_condition_surgery_age\" class=\"block mb-2 font-medium\">5a. Age your child had surgery:<\/label><input aria-invalid=\"false\" value=\"\" type=\"number\" id=\"health-history-form-1-heart_condition_surgery_age\" name=\"heart_condition_surgery_age\" class=\"w-full input\" aria-describedby=\"health-history-form-1-heart_condition_surgery_age-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.heart_condition.surgery_age\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"heart_condition\" data-field-key=\"surgery_age\"><div id=\"health-history-form-1-heart_condition_surgery_age-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Age your child had surgery: is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-heart_condition_surgery_type\" class=\"block mb-2 font-medium\">5b. What type of surgery?<\/label><input aria-invalid=\"false\" value=\"\" type=\"text\" id=\"health-history-form-1-heart_condition_surgery_type\" name=\"heart_condition_surgery_type\" class=\"w-full input\" aria-describedby=\"health-history-form-1-heart_condition_surgery_type-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.heart_condition.surgery_type\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"heart_condition\" data-field-key=\"surgery_type\"><div id=\"health-history-form-1-heart_condition_surgery_type-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">What type of surgery? is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">6. Has your child ever been hospitalized for this condition?<\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-heart_condition_been_hospitalized-yes\" name=\"heart_condition_been_hospitalized\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_been_hospitalized-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.been_hospitalized === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"heart_condition\" data-field-key=\"been_hospitalized\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-heart_condition_been_hospitalized-no\" name=\"heart_condition_been_hospitalized\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_been_hospitalized-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.been_hospitalized === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"heart_condition\" data-field-key=\"been_hospitalized\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-heart_condition_been_hospitalized-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Has your child ever been hospitalized for this condition? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-heart_condition_hospitalization_details\" class=\"block mb-2 font-medium\">6a. If yes, please provide dates and details:<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-heart_condition_hospitalization_details\" name=\"heart_condition_hospitalization_details\" class=\"w-full textarea textarea-bordered\" rows=\"3\" aria-describedby=\"health-history-form-1-heart_condition_hospitalization_details-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.heart_condition.hospitalization_details\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"heart_condition\" data-field-key=\"hospitalization_details\"><\/textarea><div id=\"health-history-form-1-heart_condition_hospitalization_details-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">If yes, please provide dates and details: is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-heart_condition_physical_limitations\" class=\"block mb-2 font-medium\">7. Does your child have any physical limitations\/restrictions or accommodations? (MD note required) If so, please describe and fill out the <a class=\"font-semibold text-blue-900 underline hover:text-gray-500\"  href='https:\/\/drive.google.com\/file\/d\/1HAFy7t8LJe_tjFf5GoooaYBmeWyo-sz9\/view?usp=sharing' target='_blank'>Medical Clearance for School Participation<\/a> form.<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-heart_condition_physical_limitations\" name=\"heart_condition_physical_limitations\" class=\"w-full textarea textarea-bordered\" rows=\"3\" aria-describedby=\"health-history-form-1-heart_condition_physical_limitations-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.heart_condition.physical_limitations\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"heart_condition\" data-field-key=\"physical_limitations\"><\/textarea><div id=\"health-history-form-1-heart_condition_physical_limitations-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Does your child have any physical limitations\/restrictions or accommodations? (MD note required) If so, please describe and fill out the <a class=\"font-semibold text-blue-900 underline hover:text-gray-500\"  href='https:\/\/drive.google.com\/file\/d\/1HAFy7t8LJe_tjFf5GoooaYBmeWyo-sz9\/view?usp=sharing' target='_blank'>Medical Clearance for School Participation<\/a> form. is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-heart_condition_medications\" class=\"block mb-2 font-medium\">8. Is your child taking medications? If so, what?<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-heart_condition_medications\" name=\"heart_condition_medications\" class=\"w-full textarea textarea-bordered\" rows=\"3\" aria-describedby=\"health-history-form-1-heart_condition_medications-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.heart_condition.medications\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"heart_condition\" data-field-key=\"medications\"><\/textarea><div id=\"health-history-form-1-heart_condition_medications-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Is your child taking medications? If so, what? is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">9. Any other information about the student's heart condition that the school staff should be aware of?<\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-heart_condition_additional_info_needed-yes\" name=\"heart_condition_additional_info_needed\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_additional_info_needed-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.additional_info_needed === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"heart_condition\" data-field-key=\"additional_info_needed\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-heart_condition_additional_info_needed-no\" name=\"heart_condition_additional_info_needed\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-heart_condition_additional_info_needed-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.heart_condition.additional_info_needed === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"heart_condition\" data-field-key=\"additional_info_needed\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-heart_condition_additional_info_needed-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Any other information about the student's heart condition that the school staff should be aware of? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-heart_condition_comments_or_additional_info\" class=\"block mb-2 font-medium\">9a. Comments or Additional Information<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-heart_condition_comments_or_additional_info\" name=\"heart_condition_comments_or_additional_info\" class=\"w-full textarea textarea-bordered\" rows=\"3\" placeholder=\"Enter any other information that the school staff should be aware of.\" aria-describedby=\"health-history-form-1-heart_condition_comments_or_additional_info-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.heart_condition.comments_or_additional_info\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"heart_condition\" data-field-key=\"comments_or_additional_info\"><\/textarea><div id=\"health-history-form-1-heart_condition_comments_or_additional_info-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Comments or Additional Information is required<\/div><\/div>\n    <\/fieldset>\n\r\n    <!-- Hemophilia -->        \r\n        <fieldset aria-hidden=\"true\" disabled hidden\n        id=\"health-history-form-1-condition-hemophilia\"\n        class=\"block md:grid md:grid-cols-12 md:items-center gap-x-5 gap-y-3 bg-base-300\/50 p-4 rounded-lg mb-6\"\n        data-wp-context='{\"conditionKey\": \"hemophilia\"}'\n        data-wp-bind--hidden=\"!state.data.conditions.hemophilia.enabled\"\n        data-wp-bind--disabled=\"!state.data.conditions.hemophilia.enabled\"\n        data-wp-bind--aria-hidden=\"!state.data.conditions.hemophilia.enabled\"\n    >\n        <legend class=\"sticky top-5 z-50 fieldset-legend bg-info text-info-content px-4 py-1 text-xs rounded-full\">\n            Hemophilia Details        <\/legend>\n\n        <div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-hemophilia_age_diagnosis\" class=\"block mb-2 font-medium\">1. Age of diagnosis<\/label><input aria-invalid=\"false\" value=\"\" type=\"number\" id=\"health-history-form-1-hemophilia_age_diagnosis\" name=\"hemophilia_age_diagnosis\" class=\"w-full input\" aria-describedby=\"health-history-form-1-hemophilia_age_diagnosis-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.hemophilia.age_diagnosis\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"hemophilia\" data-field-key=\"age_diagnosis\"><div id=\"health-history-form-1-hemophilia_age_diagnosis-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Age of diagnosis is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">2. Type of hemophilia<\/legend><div class=\"space-y-2\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-hemophilia_hemophilia_type-classic_hemophilia\" name=\"hemophilia_hemophilia_type\" value=\"classic_hemophilia\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-hemophilia_hemophilia_type-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.hemophilia.hemophilia_type === 'classic_hemophilia'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"hemophilia\" data-field-key=\"hemophilia_type\"><span class=\"label-text\">Classic Hemophilia (factor VIII deficiency)<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-hemophilia_hemophilia_type-christmas_disease\" name=\"hemophilia_hemophilia_type\" value=\"christmas_disease\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-hemophilia_hemophilia_type-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.hemophilia.hemophilia_type === 'christmas_disease'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"hemophilia\" data-field-key=\"hemophilia_type\"><span class=\"label-text\">Christmas Disease (factor IX deficiency)<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-hemophilia_hemophilia_type-von_willebrands\" name=\"hemophilia_hemophilia_type\" value=\"von_willebrands\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-hemophilia_hemophilia_type-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.hemophilia.hemophilia_type === 'von_willebrands'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"hemophilia\" data-field-key=\"hemophilia_type\"><span class=\"label-text\">Von Willebrands (VW protein deficiency)<\/span><\/label><\/div><div id=\"health-history-form-1-hemophilia_hemophilia_type-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Type of hemophilia is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">3. Severity of hemophilia<\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-hemophilia_severity-mild\" name=\"hemophilia_severity\" value=\"mild\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-hemophilia_severity-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.hemophilia.severity === 'mild'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"hemophilia\" data-field-key=\"severity\"><span class=\"label-text\">Mild<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-hemophilia_severity-moderate\" name=\"hemophilia_severity\" value=\"moderate\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-hemophilia_severity-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.hemophilia.severity === 'moderate'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"hemophilia\" data-field-key=\"severity\"><span class=\"label-text\">Moderate<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-hemophilia_severity-severe\" name=\"hemophilia_severity\" value=\"severe\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-hemophilia_severity-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.hemophilia.severity === 'severe'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"hemophilia\" data-field-key=\"severity\"><span class=\"label-text\">Severe<\/span><\/label><\/div><div id=\"health-history-form-1-hemophilia_severity-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Severity of hemophilia is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-hemophilia_replacement_therapy\" class=\"block mb-2 font-medium\">4. Type of replacement therapy?<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-hemophilia_replacement_therapy\" name=\"hemophilia_replacement_therapy\" class=\"w-full textarea textarea-bordered\" rows=\"3\" aria-describedby=\"health-history-form-1-hemophilia_replacement_therapy-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.hemophilia.replacement_therapy\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"hemophilia\" data-field-key=\"replacement_therapy\"><\/textarea><div id=\"health-history-form-1-hemophilia_replacement_therapy-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Type of replacement therapy? is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">5. Can your child tell if they are having a joint or muscle bleed?<\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-hemophilia_can_detect_bleed-yes\" name=\"hemophilia_can_detect_bleed\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-hemophilia_can_detect_bleed-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.hemophilia.can_detect_bleed === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"hemophilia\" data-field-key=\"can_detect_bleed\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-hemophilia_can_detect_bleed-no\" name=\"hemophilia_can_detect_bleed\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-hemophilia_can_detect_bleed-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.hemophilia.can_detect_bleed === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"hemophilia\" data-field-key=\"can_detect_bleed\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-hemophilia_can_detect_bleed-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Can your child tell if they are having a joint or muscle bleed? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">6. Does your child wear protective equipment?<\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-hemophilia_wears_protective_equipment-yes\" name=\"hemophilia_wears_protective_equipment\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-hemophilia_wears_protective_equipment-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.hemophilia.wears_protective_equipment === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"hemophilia\" data-field-key=\"wears_protective_equipment\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-hemophilia_wears_protective_equipment-no\" name=\"hemophilia_wears_protective_equipment\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-hemophilia_wears_protective_equipment-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.hemophilia.wears_protective_equipment === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"hemophilia\" data-field-key=\"wears_protective_equipment\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-hemophilia_wears_protective_equipment-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Does your child wear protective equipment? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-hemophilia_protective_equipment_type\" class=\"block mb-2 font-medium\">6a. If yes, type:<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-hemophilia_protective_equipment_type\" name=\"hemophilia_protective_equipment_type\" class=\"w-full textarea textarea-bordered\" rows=\"3\" aria-describedby=\"health-history-form-1-hemophilia_protective_equipment_type-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.hemophilia.protective_equipment_type\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"hemophilia\" data-field-key=\"protective_equipment_type\"><\/textarea><div id=\"health-history-form-1-hemophilia_protective_equipment_type-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">If yes, type: is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">7. Does your child have a central line?<\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-hemophilia_has_central_line-yes\" name=\"hemophilia_has_central_line\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-hemophilia_has_central_line-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.hemophilia.has_central_line === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"hemophilia\" data-field-key=\"has_central_line\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-hemophilia_has_central_line-no\" name=\"hemophilia_has_central_line\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-hemophilia_has_central_line-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.hemophilia.has_central_line === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"hemophilia\" data-field-key=\"has_central_line\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-hemophilia_has_central_line-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Does your child have a central line? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-hemophilia_restricted_activities\" class=\"block mb-2 font-medium\">8. Describe activities that your child should not participate in:<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-hemophilia_restricted_activities\" name=\"hemophilia_restricted_activities\" class=\"w-full textarea textarea-bordered\" rows=\"3\" aria-describedby=\"health-history-form-1-hemophilia_restricted_activities-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.hemophilia.restricted_activities\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"hemophilia\" data-field-key=\"restricted_activities\"><\/textarea><div id=\"health-history-form-1-hemophilia_restricted_activities-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Describe activities that your child should not participate in: is required<\/div><\/div><div class=\"col-span-12\"><h5 class=\"mb-3 text-lg font-semibold text-gray-800\">Treatment Center Information<\/h5><div class=\"block md:grid md:grid-cols-12 md:items-center gap-x-5 gap-y-3\"><div class=\"col-span-6\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-hemophilia_treatment_center_name\" class=\"block mb-2 font-medium\">9a. Name of treatment center<\/label><input aria-invalid=\"false\" value=\"\" type=\"text\" id=\"health-history-form-1-hemophilia_treatment_center_name\" name=\"hemophilia_treatment_center_name\" class=\"w-full input\" aria-describedby=\"health-history-form-1-hemophilia_treatment_center_name-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.hemophilia.treatment_center_name\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"hemophilia\" data-field-key=\"treatment_center_name\"><div id=\"health-history-form-1-hemophilia_treatment_center_name-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Name of treatment center is required<\/div><\/div><div class=\"col-span-6\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-hemophilia_treatment_center_phone\" class=\"block mb-2 font-medium\">9b. Treatment center phone<\/label><input aria-invalid=\"false\" value=\"\" type=\"tel\" id=\"health-history-form-1-hemophilia_treatment_center_phone\" name=\"hemophilia_treatment_center_phone\" class=\"w-full input\" aria-describedby=\"health-history-form-1-hemophilia_treatment_center_phone-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.hemophilia.treatment_center_phone\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"hemophilia\" data-field-key=\"treatment_center_phone\"><div id=\"health-history-form-1-hemophilia_treatment_center_phone-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Treatment center phone is required<\/div><\/div><\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-hemophilia_additional_information\" class=\"block mb-2 font-medium\">10. Any other information about the child's bleeding disorder?<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-hemophilia_additional_information\" name=\"hemophilia_additional_information\" class=\"w-full textarea textarea-bordered\" rows=\"4\" aria-describedby=\"health-history-form-1-hemophilia_additional_information-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.hemophilia.additional_information\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"hemophilia\" data-field-key=\"additional_information\"><\/textarea><div id=\"health-history-form-1-hemophilia_additional_information-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Any other information about the child's bleeding disorder? is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-hemophilia_comments_or_additional_info\" class=\"block mb-2 font-medium\">10a. Comments or Additional Information<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-hemophilia_comments_or_additional_info\" name=\"hemophilia_comments_or_additional_info\" class=\"w-full textarea textarea-bordered\" rows=\"3\" placeholder=\"Enter any other information that the school staff should be aware of.\" aria-describedby=\"health-history-form-1-hemophilia_comments_or_additional_info-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.hemophilia.comments_or_additional_info\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"hemophilia\" data-field-key=\"comments_or_additional_info\"><\/textarea><div id=\"health-history-form-1-hemophilia_comments_or_additional_info-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Comments or Additional Information is required<\/div><\/div>\n    <\/fieldset>\n\r\n    <!-- Juvenile Idiopathic Arthritis (JIA) -->\r\n        <fieldset aria-hidden=\"true\" disabled hidden\n        id=\"health-history-form-1-condition-juvenile_idiopathic_arthritis\"\n        class=\"block md:grid md:grid-cols-12 md:items-center gap-x-5 gap-y-3 bg-base-300\/50 p-4 rounded-lg mb-6\"\n        data-wp-context='{\"conditionKey\": \"juvenile_idiopathic_arthritis\"}'\n        data-wp-bind--hidden=\"!state.data.conditions.juvenile_idiopathic_arthritis.enabled\"\n        data-wp-bind--disabled=\"!state.data.conditions.juvenile_idiopathic_arthritis.enabled\"\n        data-wp-bind--aria-hidden=\"!state.data.conditions.juvenile_idiopathic_arthritis.enabled\"\n    >\n        <legend class=\"sticky top-5 z-50 fieldset-legend bg-info text-info-content px-4 py-1 text-xs rounded-full\">\n            Juvenile Idiopathic Arthritis (JIA) Details        <\/legend>\n\n        <div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-juvenile_idiopathic_arthritis_age_diagnosis\" class=\"block mb-2 font-medium\">1. Age when JIA was diagnosed<\/label><input aria-invalid=\"false\" value=\"\" type=\"number\" id=\"health-history-form-1-juvenile_idiopathic_arthritis_age_diagnosis\" name=\"juvenile_idiopathic_arthritis_age_diagnosis\" class=\"w-full input\" aria-describedby=\"health-history-form-1-juvenile_idiopathic_arthritis_age_diagnosis-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.juvenile_idiopathic_arthritis.age_diagnosis\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"juvenile_idiopathic_arthritis\" data-field-key=\"age_diagnosis\"><div id=\"health-history-form-1-juvenile_idiopathic_arthritis_age_diagnosis-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Age when JIA was diagnosed is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-juvenile_idiopathic_arthritis_affected_joints\" class=\"block mb-2 font-medium\">2. Joints and extremities that are involved<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-juvenile_idiopathic_arthritis_affected_joints\" name=\"juvenile_idiopathic_arthritis_affected_joints\" class=\"w-full textarea textarea-bordered\" rows=\"3\" aria-describedby=\"health-history-form-1-juvenile_idiopathic_arthritis_affected_joints-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.juvenile_idiopathic_arthritis.affected_joints\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"juvenile_idiopathic_arthritis\" data-field-key=\"affected_joints\"><\/textarea><div id=\"health-history-form-1-juvenile_idiopathic_arthritis_affected_joints-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Joints and extremities that are involved is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-juvenile_idiopathic_arthritis_last_severe_symptoms\" class=\"block mb-2 font-medium\">3. Last time symptoms were very severe<\/label><input aria-invalid=\"false\" value=\"\" type=\"text\" id=\"health-history-form-1-juvenile_idiopathic_arthritis_last_severe_symptoms\" name=\"juvenile_idiopathic_arthritis_last_severe_symptoms\" class=\"w-full input\" aria-describedby=\"health-history-form-1-juvenile_idiopathic_arthritis_last_severe_symptoms-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.juvenile_idiopathic_arthritis.last_severe_symptoms\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"juvenile_idiopathic_arthritis\" data-field-key=\"last_severe_symptoms\"><div id=\"health-history-form-1-juvenile_idiopathic_arthritis_last_severe_symptoms-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Last time symptoms were very severe is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">4. Is your child currently taking any JIA medication?<\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-juvenile_idiopathic_arthritis_currently_taking_medication-yes\" name=\"juvenile_idiopathic_arthritis_currently_taking_medication\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-juvenile_idiopathic_arthritis_currently_taking_medication-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.juvenile_idiopathic_arthritis.currently_taking_medication === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"juvenile_idiopathic_arthritis\" data-field-key=\"currently_taking_medication\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-juvenile_idiopathic_arthritis_currently_taking_medication-no\" name=\"juvenile_idiopathic_arthritis_currently_taking_medication\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-juvenile_idiopathic_arthritis_currently_taking_medication-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.juvenile_idiopathic_arthritis.currently_taking_medication === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"juvenile_idiopathic_arthritis\" data-field-key=\"currently_taking_medication\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-juvenile_idiopathic_arthritis_currently_taking_medication-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Is your child currently taking any JIA medication? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-juvenile_idiopathic_arthritis_current_medications\" class=\"block mb-2 font-medium\">4a. If yes, list medication\/s, dose and time<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-juvenile_idiopathic_arthritis_current_medications\" name=\"juvenile_idiopathic_arthritis_current_medications\" class=\"w-full textarea textarea-bordered\" rows=\"4\" aria-describedby=\"health-history-form-1-juvenile_idiopathic_arthritis_current_medications-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.juvenile_idiopathic_arthritis.current_medications\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"juvenile_idiopathic_arthritis\" data-field-key=\"current_medications\"><\/textarea><div id=\"health-history-form-1-juvenile_idiopathic_arthritis_current_medications-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">If yes, list medication\/s, dose and time is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">5. Has your child taken medication for JIA in the past?<\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-juvenile_idiopathic_arthritis_past_medication-yes\" name=\"juvenile_idiopathic_arthritis_past_medication\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-juvenile_idiopathic_arthritis_past_medication-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.juvenile_idiopathic_arthritis.past_medication === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"juvenile_idiopathic_arthritis\" data-field-key=\"past_medication\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-juvenile_idiopathic_arthritis_past_medication-no\" name=\"juvenile_idiopathic_arthritis_past_medication\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-juvenile_idiopathic_arthritis_past_medication-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.juvenile_idiopathic_arthritis.past_medication === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"juvenile_idiopathic_arthritis\" data-field-key=\"past_medication\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-juvenile_idiopathic_arthritis_past_medication-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Has your child taken medication for JIA in the past? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-juvenile_idiopathic_arthritis_past_medications_list\" class=\"block mb-2 font-medium\">5a. If yes, list medication(s). <br \/> <span class='text-sm'> If medications are needed to be taken at school, please complete <a class=\"font-semibold text-blue-900 underline hover:text-gray-500\"  href='https:\/\/drive.google.com\/file\/d\/0B44Boq3d-4RbQlpqVFR5ZjFzazg\/view?usp=sharing&amp;resourcekey=0-UPKGerwPOJ8o5_4weKB2_g' target='_blank'>Parent\/Guardian and authorized health care provider request for medication<\/a>.<\/span>'<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-juvenile_idiopathic_arthritis_past_medications_list\" name=\"juvenile_idiopathic_arthritis_past_medications_list\" class=\"w-full textarea textarea-bordered\" rows=\"4\" aria-describedby=\"health-history-form-1-juvenile_idiopathic_arthritis_past_medications_list-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.juvenile_idiopathic_arthritis.past_medications_list\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"juvenile_idiopathic_arthritis\" data-field-key=\"past_medications_list\"><\/textarea><div id=\"health-history-form-1-juvenile_idiopathic_arthritis_past_medications_list-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">If yes, list medication(s). <br \/> <span class='text-sm'> If medications are needed to be taken at school, please complete <a class=\"font-semibold text-blue-900 underline hover:text-gray-500\"  href='https:\/\/drive.google.com\/file\/d\/0B44Boq3d-4RbQlpqVFR5ZjFzazg\/view?usp=sharing&amp;resourcekey=0-UPKGerwPOJ8o5_4weKB2_g' target='_blank'>Parent\/Guardian and authorized health care provider request for medication<\/a>.<\/span>' is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">6. Type of JIA<\/legend><div class=\"space-y-2\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-juvenile_idiopathic_arthritis_jia_type-systemic\" name=\"juvenile_idiopathic_arthritis_jia_type\" value=\"systemic\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-juvenile_idiopathic_arthritis_jia_type-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.juvenile_idiopathic_arthritis.jia_type === 'systemic'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"juvenile_idiopathic_arthritis\" data-field-key=\"jia_type\"><span class=\"label-text\">Systemic JIA<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-juvenile_idiopathic_arthritis_jia_type-polyarticular\" name=\"juvenile_idiopathic_arthritis_jia_type\" value=\"polyarticular\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-juvenile_idiopathic_arthritis_jia_type-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.juvenile_idiopathic_arthritis.jia_type === 'polyarticular'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"juvenile_idiopathic_arthritis\" data-field-key=\"jia_type\"><span class=\"label-text\">Polyarticular JIA<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-juvenile_idiopathic_arthritis_jia_type-oligoarticular\" name=\"juvenile_idiopathic_arthritis_jia_type\" value=\"oligoarticular\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-juvenile_idiopathic_arthritis_jia_type-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.juvenile_idiopathic_arthritis.jia_type === 'oligoarticular'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"juvenile_idiopathic_arthritis\" data-field-key=\"jia_type\"><span class=\"label-text\">Oligoarticular JIA<\/span><\/label><\/div><div id=\"health-history-form-1-juvenile_idiopathic_arthritis_jia_type-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Type of JIA is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">7. Does your child have any activity restrictions?<\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-juvenile_idiopathic_arthritis_has_activity_restrictions-yes\" name=\"juvenile_idiopathic_arthritis_has_activity_restrictions\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-juvenile_idiopathic_arthritis_has_activity_restrictions-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.juvenile_idiopathic_arthritis.has_activity_restrictions === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"juvenile_idiopathic_arthritis\" data-field-key=\"has_activity_restrictions\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-juvenile_idiopathic_arthritis_has_activity_restrictions-no\" name=\"juvenile_idiopathic_arthritis_has_activity_restrictions\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-juvenile_idiopathic_arthritis_has_activity_restrictions-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.juvenile_idiopathic_arthritis.has_activity_restrictions === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"juvenile_idiopathic_arthritis\" data-field-key=\"has_activity_restrictions\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-juvenile_idiopathic_arthritis_has_activity_restrictions-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Does your child have any activity restrictions? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-juvenile_idiopathic_arthritis_activity_restrictions_explanation\" class=\"block mb-2 font-medium\">7a. Explain<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-juvenile_idiopathic_arthritis_activity_restrictions_explanation\" name=\"juvenile_idiopathic_arthritis_activity_restrictions_explanation\" class=\"w-full textarea textarea-bordered\" rows=\"3\" aria-describedby=\"health-history-form-1-juvenile_idiopathic_arthritis_activity_restrictions_explanation-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.juvenile_idiopathic_arthritis.activity_restrictions_explanation\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"juvenile_idiopathic_arthritis\" data-field-key=\"activity_restrictions_explanation\"><\/textarea><div id=\"health-history-form-1-juvenile_idiopathic_arthritis_activity_restrictions_explanation-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Explain is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-juvenile_idiopathic_arthritis_comments_or_additional_info\" class=\"block mb-2 font-medium\">8. Comments or Additional Information<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-juvenile_idiopathic_arthritis_comments_or_additional_info\" name=\"juvenile_idiopathic_arthritis_comments_or_additional_info\" class=\"w-full textarea textarea-bordered\" rows=\"3\" placeholder=\"Enter any other information that the school staff should be aware of.\" aria-describedby=\"health-history-form-1-juvenile_idiopathic_arthritis_comments_or_additional_info-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.juvenile_idiopathic_arthritis.comments_or_additional_info\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"juvenile_idiopathic_arthritis\" data-field-key=\"comments_or_additional_info\"><\/textarea><div id=\"health-history-form-1-juvenile_idiopathic_arthritis_comments_or_additional_info-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Comments or Additional Information is required<\/div><\/div>\n    <\/fieldset>\n\r\n    <!-- Nephrotic Syndrome -->\r\n        <fieldset aria-hidden=\"true\" disabled hidden\n        id=\"health-history-form-1-condition-nephrotic_syndrome\"\n        class=\"block md:grid md:grid-cols-12 md:items-center gap-x-5 gap-y-3 bg-base-300\/50 p-4 rounded-lg mb-6\"\n        data-wp-context='{\"conditionKey\": \"nephrotic_syndrome\"}'\n        data-wp-bind--hidden=\"!state.data.conditions.nephrotic_syndrome.enabled\"\n        data-wp-bind--disabled=\"!state.data.conditions.nephrotic_syndrome.enabled\"\n        data-wp-bind--aria-hidden=\"!state.data.conditions.nephrotic_syndrome.enabled\"\n    >\n        <legend class=\"sticky top-5 z-50 fieldset-legend bg-info text-info-content px-4 py-1 text-xs rounded-full\">\n            Nephrotic Syndrome Details        <\/legend>\n\n        <div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-nephrotic_syndrome_age_diagnosis\" class=\"block mb-2 font-medium\">1. Age diagnosed with Nephrotic Syndrome?<\/label><input aria-invalid=\"false\" value=\"\" type=\"number\" id=\"health-history-form-1-nephrotic_syndrome_age_diagnosis\" name=\"nephrotic_syndrome_age_diagnosis\" class=\"w-full input\" aria-describedby=\"health-history-form-1-nephrotic_syndrome_age_diagnosis-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.nephrotic_syndrome.age_diagnosis\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"age_diagnosis\"><div id=\"health-history-form-1-nephrotic_syndrome_age_diagnosis-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Age diagnosed with Nephrotic Syndrome? is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false, \"numItems\": 1 }'><fieldset class=\"repeater-group\"><legend class=\"block px-2 mb-3 font-medium\">2. Dates of last relapses<\/legend><div class=\"p-3 mb-2 rounded-lg bg-base-200\/50\" data-wp-context='{\"itemIndex\": 1 }' data-wp-bind--hidden=\"context.numItems < context.itemIndex\"><h6 class=\"mb-2 text-sm font-semibold\">Relapse #1<\/h6><div class=\"grid grid-cols-12 gap-3\"><div class=\"col-span-12 md:col-span-6\"><label for=\"health-history-form-1-nephrotic_syndrome_relapses-1-date\" class=\"block mb-1 text-sm\">Date<\/label><input type=\"text\" id=\"health-history-form-1-nephrotic_syndrome_relapses-1-date\" name=\"nephrotic_syndrome_relapses[1][date]\" class=\"w-full input input-bordered input-sm\" placeholder=\"e.g., March 2024\" data-wp-bind--value=\"state.data.conditions.nephrotic_syndrome.relapses[0]?.date\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"relapses\"><\/div><div class=\"col-span-12 md:col-span-6\"><label for=\"health-history-form-1-nephrotic_syndrome_relapses-1-symptoms\" class=\"block mb-1 text-sm\">Symptoms<\/label><input type=\"text\" id=\"health-history-form-1-nephrotic_syndrome_relapses-1-symptoms\" name=\"nephrotic_syndrome_relapses[1][symptoms]\" class=\"w-full input input-bordered input-sm\" placeholder=\"Describe symptoms...\" data-wp-bind--value=\"state.data.conditions.nephrotic_syndrome.relapses[0]?.symptoms\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"relapses\"><\/div><\/div><\/div><div class=\"p-3 mb-2 rounded-lg bg-base-200\/50\" data-wp-context='{\"itemIndex\": 2 }' data-wp-bind--hidden=\"context.numItems < context.itemIndex\"><h6 class=\"mb-2 text-sm font-semibold\">Relapse #2<\/h6><div class=\"grid grid-cols-12 gap-3\"><div class=\"col-span-12 md:col-span-6\"><label for=\"health-history-form-1-nephrotic_syndrome_relapses-2-date\" class=\"block mb-1 text-sm\">Date<\/label><input type=\"text\" id=\"health-history-form-1-nephrotic_syndrome_relapses-2-date\" name=\"nephrotic_syndrome_relapses[2][date]\" class=\"w-full input input-bordered input-sm\" placeholder=\"e.g., March 2024\" data-wp-bind--value=\"state.data.conditions.nephrotic_syndrome.relapses[1]?.date\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"relapses\"><\/div><div class=\"col-span-12 md:col-span-6\"><label for=\"health-history-form-1-nephrotic_syndrome_relapses-2-symptoms\" class=\"block mb-1 text-sm\">Symptoms<\/label><input type=\"text\" id=\"health-history-form-1-nephrotic_syndrome_relapses-2-symptoms\" name=\"nephrotic_syndrome_relapses[2][symptoms]\" class=\"w-full input input-bordered input-sm\" placeholder=\"Describe symptoms...\" data-wp-bind--value=\"state.data.conditions.nephrotic_syndrome.relapses[1]?.symptoms\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"relapses\"><\/div><\/div><\/div><div class=\"p-3 mb-2 rounded-lg bg-base-200\/50\" data-wp-context='{\"itemIndex\": 3 }' data-wp-bind--hidden=\"context.numItems < context.itemIndex\"><h6 class=\"mb-2 text-sm font-semibold\">Relapse #3<\/h6><div class=\"grid grid-cols-12 gap-3\"><div class=\"col-span-12 md:col-span-6\"><label for=\"health-history-form-1-nephrotic_syndrome_relapses-3-date\" class=\"block mb-1 text-sm\">Date<\/label><input type=\"text\" id=\"health-history-form-1-nephrotic_syndrome_relapses-3-date\" name=\"nephrotic_syndrome_relapses[3][date]\" class=\"w-full input input-bordered input-sm\" placeholder=\"e.g., March 2024\" data-wp-bind--value=\"state.data.conditions.nephrotic_syndrome.relapses[2]?.date\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"relapses\"><\/div><div class=\"col-span-12 md:col-span-6\"><label for=\"health-history-form-1-nephrotic_syndrome_relapses-3-symptoms\" class=\"block mb-1 text-sm\">Symptoms<\/label><input type=\"text\" id=\"health-history-form-1-nephrotic_syndrome_relapses-3-symptoms\" name=\"nephrotic_syndrome_relapses[3][symptoms]\" class=\"w-full input input-bordered input-sm\" placeholder=\"Describe symptoms...\" data-wp-bind--value=\"state.data.conditions.nephrotic_syndrome.relapses[2]?.symptoms\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"relapses\"><\/div><\/div><\/div><div class=\"p-3 mb-2 rounded-lg bg-base-200\/50\" data-wp-context='{\"itemIndex\": 4 }' data-wp-bind--hidden=\"context.numItems < context.itemIndex\"><h6 class=\"mb-2 text-sm font-semibold\">Relapse #4<\/h6><div class=\"grid grid-cols-12 gap-3\"><div class=\"col-span-12 md:col-span-6\"><label for=\"health-history-form-1-nephrotic_syndrome_relapses-4-date\" class=\"block mb-1 text-sm\">Date<\/label><input type=\"text\" id=\"health-history-form-1-nephrotic_syndrome_relapses-4-date\" name=\"nephrotic_syndrome_relapses[4][date]\" class=\"w-full input input-bordered input-sm\" placeholder=\"e.g., March 2024\" data-wp-bind--value=\"state.data.conditions.nephrotic_syndrome.relapses[3]?.date\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"relapses\"><\/div><div class=\"col-span-12 md:col-span-6\"><label for=\"health-history-form-1-nephrotic_syndrome_relapses-4-symptoms\" class=\"block mb-1 text-sm\">Symptoms<\/label><input type=\"text\" id=\"health-history-form-1-nephrotic_syndrome_relapses-4-symptoms\" name=\"nephrotic_syndrome_relapses[4][symptoms]\" class=\"w-full input input-bordered input-sm\" placeholder=\"Describe symptoms...\" data-wp-bind--value=\"state.data.conditions.nephrotic_syndrome.relapses[3]?.symptoms\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"relapses\"><\/div><\/div><\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-nephrotic_syndrome_relapses_per_year\" class=\"block mb-2 font-medium\">3. Frequency of relapses per year?<\/label><input aria-invalid=\"false\" value=\"\" type=\"number\" id=\"health-history-form-1-nephrotic_syndrome_relapses_per_year\" name=\"nephrotic_syndrome_relapses_per_year\" class=\"w-full input\" aria-describedby=\"health-history-form-1-nephrotic_syndrome_relapses_per_year-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.nephrotic_syndrome.relapses_per_year\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"relapses_per_year\"><div id=\"health-history-form-1-nephrotic_syndrome_relapses_per_year-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Frequency of relapses per year? is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false, \"numItems\": 1 }'><fieldset class=\"repeater-group\"><legend class=\"block px-2 mb-3 font-medium\">4. Current medications<\/legend><div class=\"p-3 mb-2 rounded-lg bg-base-200\/50\" data-wp-context='{\"itemIndex\": 1 }' data-wp-bind--hidden=\"context.numItems < context.itemIndex\"><h6 class=\"mb-2 text-sm font-semibold\">Medication #1<\/h6><div class=\"grid grid-cols-12 gap-3\"><div class=\"col-span-12 md:col-span-4\"><label for=\"health-history-form-1-nephrotic_syndrome_medications-1-name\" class=\"block mb-1 text-sm\">Name<\/label><input type=\"text\" id=\"health-history-form-1-nephrotic_syndrome_medications-1-name\" name=\"nephrotic_syndrome_medications[1][name]\" class=\"w-full input input-bordered input-sm\" placeholder=\"Medication name...\" data-wp-bind--value=\"state.data.conditions.nephrotic_syndrome.medications[0]?.name\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"medications\"><\/div><div class=\"col-span-12 md:col-span-4\"><label for=\"health-history-form-1-nephrotic_syndrome_medications-1-dose\" class=\"block mb-1 text-sm\">Dose<\/label><input type=\"text\" id=\"health-history-form-1-nephrotic_syndrome_medications-1-dose\" name=\"nephrotic_syndrome_medications[1][dose]\" class=\"w-full input input-bordered input-sm\" placeholder=\"e.g., 5mg\" data-wp-bind--value=\"state.data.conditions.nephrotic_syndrome.medications[0]?.dose\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"medications\"><\/div><div class=\"col-span-12 md:col-span-4\"><label for=\"health-history-form-1-nephrotic_syndrome_medications-1-time\" class=\"block mb-1 text-sm\">Time<\/label><input type=\"text\" id=\"health-history-form-1-nephrotic_syndrome_medications-1-time\" name=\"nephrotic_syndrome_medications[1][time]\" class=\"w-full input input-bordered input-sm\" placeholder=\"e.g., Morning\" data-wp-bind--value=\"state.data.conditions.nephrotic_syndrome.medications[0]?.time\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"medications\"><\/div><\/div><\/div><div class=\"p-3 mb-2 rounded-lg bg-base-200\/50\" data-wp-context='{\"itemIndex\": 2 }' data-wp-bind--hidden=\"context.numItems < context.itemIndex\"><h6 class=\"mb-2 text-sm font-semibold\">Medication #2<\/h6><div class=\"grid grid-cols-12 gap-3\"><div class=\"col-span-12 md:col-span-4\"><label for=\"health-history-form-1-nephrotic_syndrome_medications-2-name\" class=\"block mb-1 text-sm\">Name<\/label><input type=\"text\" id=\"health-history-form-1-nephrotic_syndrome_medications-2-name\" name=\"nephrotic_syndrome_medications[2][name]\" class=\"w-full input input-bordered input-sm\" placeholder=\"Medication name...\" data-wp-bind--value=\"state.data.conditions.nephrotic_syndrome.medications[1]?.name\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"medications\"><\/div><div class=\"col-span-12 md:col-span-4\"><label for=\"health-history-form-1-nephrotic_syndrome_medications-2-dose\" class=\"block mb-1 text-sm\">Dose<\/label><input type=\"text\" id=\"health-history-form-1-nephrotic_syndrome_medications-2-dose\" name=\"nephrotic_syndrome_medications[2][dose]\" class=\"w-full input input-bordered input-sm\" placeholder=\"e.g., 5mg\" data-wp-bind--value=\"state.data.conditions.nephrotic_syndrome.medications[1]?.dose\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"medications\"><\/div><div class=\"col-span-12 md:col-span-4\"><label for=\"health-history-form-1-nephrotic_syndrome_medications-2-time\" class=\"block mb-1 text-sm\">Time<\/label><input type=\"text\" id=\"health-history-form-1-nephrotic_syndrome_medications-2-time\" name=\"nephrotic_syndrome_medications[2][time]\" class=\"w-full input input-bordered input-sm\" placeholder=\"e.g., Morning\" data-wp-bind--value=\"state.data.conditions.nephrotic_syndrome.medications[1]?.time\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"medications\"><\/div><\/div><\/div><div class=\"p-3 mb-2 rounded-lg bg-base-200\/50\" data-wp-context='{\"itemIndex\": 3 }' data-wp-bind--hidden=\"context.numItems < context.itemIndex\"><h6 class=\"mb-2 text-sm font-semibold\">Medication #3<\/h6><div class=\"grid grid-cols-12 gap-3\"><div class=\"col-span-12 md:col-span-4\"><label for=\"health-history-form-1-nephrotic_syndrome_medications-3-name\" class=\"block mb-1 text-sm\">Name<\/label><input type=\"text\" id=\"health-history-form-1-nephrotic_syndrome_medications-3-name\" name=\"nephrotic_syndrome_medications[3][name]\" class=\"w-full input input-bordered input-sm\" placeholder=\"Medication name...\" data-wp-bind--value=\"state.data.conditions.nephrotic_syndrome.medications[2]?.name\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"medications\"><\/div><div class=\"col-span-12 md:col-span-4\"><label for=\"health-history-form-1-nephrotic_syndrome_medications-3-dose\" class=\"block mb-1 text-sm\">Dose<\/label><input type=\"text\" id=\"health-history-form-1-nephrotic_syndrome_medications-3-dose\" name=\"nephrotic_syndrome_medications[3][dose]\" class=\"w-full input input-bordered input-sm\" placeholder=\"e.g., 5mg\" data-wp-bind--value=\"state.data.conditions.nephrotic_syndrome.medications[2]?.dose\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"medications\"><\/div><div class=\"col-span-12 md:col-span-4\"><label for=\"health-history-form-1-nephrotic_syndrome_medications-3-time\" class=\"block mb-1 text-sm\">Time<\/label><input type=\"text\" id=\"health-history-form-1-nephrotic_syndrome_medications-3-time\" name=\"nephrotic_syndrome_medications[3][time]\" class=\"w-full input input-bordered input-sm\" placeholder=\"e.g., Morning\" data-wp-bind--value=\"state.data.conditions.nephrotic_syndrome.medications[2]?.time\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"medications\"><\/div><\/div><\/div><div class=\"p-3 mb-2 rounded-lg bg-base-200\/50\" data-wp-context='{\"itemIndex\": 4 }' data-wp-bind--hidden=\"context.numItems < context.itemIndex\"><h6 class=\"mb-2 text-sm font-semibold\">Medication #4<\/h6><div class=\"grid grid-cols-12 gap-3\"><div class=\"col-span-12 md:col-span-4\"><label for=\"health-history-form-1-nephrotic_syndrome_medications-4-name\" class=\"block mb-1 text-sm\">Name<\/label><input type=\"text\" id=\"health-history-form-1-nephrotic_syndrome_medications-4-name\" name=\"nephrotic_syndrome_medications[4][name]\" class=\"w-full input input-bordered input-sm\" placeholder=\"Medication name...\" data-wp-bind--value=\"state.data.conditions.nephrotic_syndrome.medications[3]?.name\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"medications\"><\/div><div class=\"col-span-12 md:col-span-4\"><label for=\"health-history-form-1-nephrotic_syndrome_medications-4-dose\" class=\"block mb-1 text-sm\">Dose<\/label><input type=\"text\" id=\"health-history-form-1-nephrotic_syndrome_medications-4-dose\" name=\"nephrotic_syndrome_medications[4][dose]\" class=\"w-full input input-bordered input-sm\" placeholder=\"e.g., 5mg\" data-wp-bind--value=\"state.data.conditions.nephrotic_syndrome.medications[3]?.dose\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"medications\"><\/div><div class=\"col-span-12 md:col-span-4\"><label for=\"health-history-form-1-nephrotic_syndrome_medications-4-time\" class=\"block mb-1 text-sm\">Time<\/label><input type=\"text\" id=\"health-history-form-1-nephrotic_syndrome_medications-4-time\" name=\"nephrotic_syndrome_medications[4][time]\" class=\"w-full input input-bordered input-sm\" placeholder=\"e.g., Morning\" data-wp-bind--value=\"state.data.conditions.nephrotic_syndrome.medications[3]?.time\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"medications\"><\/div><\/div><\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">5. Does your child have a modified diet? <br \/> <span class='text-sm'>(If yes, please also complete the '<a class=\"font-semibold text-blue-900 underline hover:text-gray-500\"  href='https:\/\/drive.google.com\/file\/d\/1duFLA0uvNddNureO94HA225Um9FcfYHJ\/view?usp=sharing' target='_blank'>Medical Statement to Request Special Meal Accommodations<\/a>' form)<\/span><\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-nephrotic_syndrome_has_modified_diet-yes\" name=\"nephrotic_syndrome_has_modified_diet\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-nephrotic_syndrome_has_modified_diet-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.nephrotic_syndrome.has_modified_diet === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"has_modified_diet\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-nephrotic_syndrome_has_modified_diet-no\" name=\"nephrotic_syndrome_has_modified_diet\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-nephrotic_syndrome_has_modified_diet-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.nephrotic_syndrome.has_modified_diet === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"has_modified_diet\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-nephrotic_syndrome_has_modified_diet-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Does your child have a modified diet? <br \/> <span class='text-sm'>(If yes, please also complete the '<a class=\"font-semibold text-blue-900 underline hover:text-gray-500\"  href='https:\/\/drive.google.com\/file\/d\/1duFLA0uvNddNureO94HA225Um9FcfYHJ\/view?usp=sharing' target='_blank'>Medical Statement to Request Special Meal Accommodations<\/a>' form)<\/span> is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">6. Does your child have a fluid restriction? (Healthcare provider note needed)<\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-nephrotic_syndrome_has_fluid_restriction-yes\" name=\"nephrotic_syndrome_has_fluid_restriction\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-nephrotic_syndrome_has_fluid_restriction-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.nephrotic_syndrome.has_fluid_restriction === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"has_fluid_restriction\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-nephrotic_syndrome_has_fluid_restriction-no\" name=\"nephrotic_syndrome_has_fluid_restriction\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-nephrotic_syndrome_has_fluid_restriction-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.nephrotic_syndrome.has_fluid_restriction === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"has_fluid_restriction\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-nephrotic_syndrome_has_fluid_restriction-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Does your child have a fluid restriction? (Healthcare provider note needed) is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-nephrotic_syndrome_fluid_limit\" class=\"block mb-2 font-medium\">6a. If yes, what is your child's fluid limit?<\/label><input aria-invalid=\"false\" value=\"\" type=\"text\" id=\"health-history-form-1-nephrotic_syndrome_fluid_limit\" name=\"nephrotic_syndrome_fluid_limit\" class=\"w-full input\" placeholder=\"e.g., 1000ml per day\" aria-describedby=\"health-history-form-1-nephrotic_syndrome_fluid_limit-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.nephrotic_syndrome.fluid_limit\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"fluid_limit\"><div id=\"health-history-form-1-nephrotic_syndrome_fluid_limit-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">If yes, what is your child's fluid limit? is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">6b. Does your child monitor fluid intake and output?<\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-nephrotic_syndrome_monitors_fluid_intake-yes\" name=\"nephrotic_syndrome_monitors_fluid_intake\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-nephrotic_syndrome_monitors_fluid_intake-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.nephrotic_syndrome.monitors_fluid_intake === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"monitors_fluid_intake\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-nephrotic_syndrome_monitors_fluid_intake-no\" name=\"nephrotic_syndrome_monitors_fluid_intake\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-nephrotic_syndrome_monitors_fluid_intake-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.nephrotic_syndrome.monitors_fluid_intake === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"monitors_fluid_intake\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-nephrotic_syndrome_monitors_fluid_intake-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Does your child monitor fluid intake and output? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">7. Does your child monitor protein clearance with urine dipstick testing? (Healthcare provider note needed)<\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-nephrotic_syndrome_monitors_protein_clearance-yes\" name=\"nephrotic_syndrome_monitors_protein_clearance\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-nephrotic_syndrome_monitors_protein_clearance-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.nephrotic_syndrome.monitors_protein_clearance === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"monitors_protein_clearance\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-nephrotic_syndrome_monitors_protein_clearance-no\" name=\"nephrotic_syndrome_monitors_protein_clearance\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-nephrotic_syndrome_monitors_protein_clearance-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.nephrotic_syndrome.monitors_protein_clearance === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"monitors_protein_clearance\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-nephrotic_syndrome_monitors_protein_clearance-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Does your child monitor protein clearance with urine dipstick testing? (Healthcare provider note needed) is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">8. Does your child need to test his\/her urine at school?<\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-nephrotic_syndrome_needs_urine_testing_at_school-yes\" name=\"nephrotic_syndrome_needs_urine_testing_at_school\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-nephrotic_syndrome_needs_urine_testing_at_school-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.nephrotic_syndrome.needs_urine_testing_at_school === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"needs_urine_testing_at_school\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-nephrotic_syndrome_needs_urine_testing_at_school-no\" name=\"nephrotic_syndrome_needs_urine_testing_at_school\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-nephrotic_syndrome_needs_urine_testing_at_school-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.nephrotic_syndrome.needs_urine_testing_at_school === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"needs_urine_testing_at_school\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-nephrotic_syndrome_needs_urine_testing_at_school-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Does your child need to test his\/her urine at school? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-nephrotic_syndrome_comments_or_additional_info\" class=\"block mb-2 font-medium\">9. Comments or Additional Information<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-nephrotic_syndrome_comments_or_additional_info\" name=\"nephrotic_syndrome_comments_or_additional_info\" class=\"w-full textarea textarea-bordered\" rows=\"3\" placeholder=\"Enter any other information that the school staff should be aware of.\" aria-describedby=\"health-history-form-1-nephrotic_syndrome_comments_or_additional_info-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.nephrotic_syndrome.comments_or_additional_info\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"nephrotic_syndrome\" data-field-key=\"comments_or_additional_info\"><\/textarea><div id=\"health-history-form-1-nephrotic_syndrome_comments_or_additional_info-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Comments or Additional Information is required<\/div><\/div>\n    <\/fieldset>\n\r\n    <!-- Seizure History -->\r\n        <fieldset aria-hidden=\"true\" disabled hidden\n        id=\"health-history-form-1-condition-seizure_history\"\n        class=\"block md:grid md:grid-cols-12 md:items-center gap-x-5 gap-y-3 bg-base-300\/50 p-4 rounded-lg mb-6\"\n        data-wp-context='{\"conditionKey\": \"seizure_history\"}'\n        data-wp-bind--hidden=\"!state.data.conditions.seizure_history.enabled\"\n        data-wp-bind--disabled=\"!state.data.conditions.seizure_history.enabled\"\n        data-wp-bind--aria-hidden=\"!state.data.conditions.seizure_history.enabled\"\n    >\n        <legend class=\"sticky top-5 z-50 fieldset-legend bg-info text-info-content px-4 py-1 text-xs rounded-full\">\n            Seizure History Details        <\/legend>\n\n        <div class=\"col-span-6\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-seizure_history_age_first_seizure\" class=\"block mb-2 font-medium\">1. Age of first seizure?<\/label><input aria-invalid=\"false\" value=\"\" type=\"number\" id=\"health-history-form-1-seizure_history_age_first_seizure\" name=\"seizure_history_age_first_seizure\" class=\"w-full input\" aria-describedby=\"health-history-form-1-seizure_history_age_first_seizure-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.seizure_history.age_first_seizure\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"seizure_history\" data-field-key=\"age_first_seizure\"><div id=\"health-history-form-1-seizure_history_age_first_seizure-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Age of first seizure? is required<\/div><\/div><div class=\"col-span-6\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-seizure_history_seizure_frequency\" class=\"block mb-2 font-medium\">2. How often do seizures occur?<\/label><input aria-invalid=\"false\" value=\"\" type=\"text\" id=\"health-history-form-1-seizure_history_seizure_frequency\" name=\"seizure_history_seizure_frequency\" class=\"w-full input\" aria-describedby=\"health-history-form-1-seizure_history_seizure_frequency-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.seizure_history.seizure_frequency\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"seizure_history\" data-field-key=\"seizure_frequency\"><div id=\"health-history-form-1-seizure_history_seizure_frequency-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">How often do seizures occur? is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-seizure_history_seizure_type\"><span class=\"label-text\">3. Type of seizure?<\/span><\/label><select value=\"\" id=\"health-history-form-1-seizure_history_seizure_type\" name=\"seizure_history_seizure_type\" class=\"w-full select select-bordered\" data-wp-bind--value=\"state.data.conditions.seizure_history.seizure_type\" data-wp-on--input=\"actions.updateConditionField\" data-wp-on--blur=\"actions.validateSelectField\" data-condition-key=\"seizure_history\" data-field-key=\"seizure_type\"><option value=\"\" disabled>Select seizure type<\/option><option value=\"generalized_tonic_clonic\">Generalized tonic-clonic<\/option><option value=\"absence\">Absence<\/option><option value=\"focal_aware\">Focal aware<\/option><option value=\"focal_impaired_awareness\">Focal impaired awareness<\/option><option value=\"atonic\">Atonic<\/option><option value=\"myoclonic\">Myoclonic<\/option><option value=\"unknown_type\">Unknown type<\/option><\/select><div id=\"health-history-form-1-seizure_history_seizure_type-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Type of seizure? is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-seizure_history_current_medications\" class=\"block mb-2 font-medium\">4. Current medications<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-seizure_history_current_medications\" name=\"seizure_history_current_medications\" class=\"w-full textarea textarea-bordered\" rows=\"4\" aria-describedby=\"health-history-form-1-seizure_history_current_medications-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.seizure_history.current_medications\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"seizure_history\" data-field-key=\"current_medications\"><\/textarea><div id=\"health-history-form-1-seizure_history_current_medications-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Current medications is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-seizure_history_medication_side_effects\" class=\"block mb-2 font-medium\">5. Medication side effects?<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-seizure_history_medication_side_effects\" name=\"seizure_history_medication_side_effects\" class=\"w-full textarea textarea-bordered\" rows=\"3\" aria-describedby=\"health-history-form-1-seizure_history_medication_side_effects-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.seizure_history.medication_side_effects\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"seizure_history\" data-field-key=\"medication_side_effects\"><\/textarea><div id=\"health-history-form-1-seizure_history_medication_side_effects-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Medication side effects? is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-seizure_history_seizure_triggers\" class=\"block mb-2 font-medium\">6. Known seizure triggers?<\/label><input aria-invalid=\"false\" value=\"\" type=\"text\" id=\"health-history-form-1-seizure_history_seizure_triggers\" name=\"seizure_history_seizure_triggers\" class=\"w-full input\" aria-describedby=\"health-history-form-1-seizure_history_seizure_triggers-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.seizure_history.seizure_triggers\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"seizure_history\" data-field-key=\"seizure_triggers\"><div id=\"health-history-form-1-seizure_history_seizure_triggers-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Known seizure triggers? is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-seizure_history_last_seizure_date\"><span class=\"label-text\">7. Date of last seizure<\/span><\/label><input value=\"\" type=\"date\" id=\"health-history-form-1-seizure_history_last_seizure_date\" name=\"seizure_history_last_seizure_date\" class=\"w-full input input-bordered\" data-wp-bind--value=\"state.data.conditions.seizure_history.last_seizure_date\" data-wp-on--input=\"actions.updateConditionField\" data-wp-on--blur=\"actions.validateTextField\" data-condition-key=\"seizure_history\" data-field-key=\"last_seizure_date\"><div id=\"health-history-form-1-seizure_history_last_seizure_date-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Date of last seizure is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-seizure_history_seizure_duration\" class=\"block mb-2 font-medium\">8. Typical seizure duration (minutes)<\/label><input aria-invalid=\"false\" value=\"\" type=\"number\" id=\"health-history-form-1-seizure_history_seizure_duration\" name=\"seizure_history_seizure_duration\" class=\"w-full input\" aria-describedby=\"health-history-form-1-seizure_history_seizure_duration-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.seizure_history.seizure_duration\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"seizure_history\" data-field-key=\"seizure_duration\"><div id=\"health-history-form-1-seizure_history_seizure_duration-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Typical seizure duration (minutes) is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-seizure_history_post_seizure_behavior\" class=\"block mb-2 font-medium\">9. Post-seizure behavior<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-seizure_history_post_seizure_behavior\" name=\"seizure_history_post_seizure_behavior\" class=\"w-full textarea textarea-bordered\" rows=\"3\" aria-describedby=\"health-history-form-1-seizure_history_post_seizure_behavior-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.seizure_history.post_seizure_behavior\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"seizure_history\" data-field-key=\"post_seizure_behavior\"><\/textarea><div id=\"health-history-form-1-seizure_history_post_seizure_behavior-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Post-seizure behavior is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">10. Does the student have emergency medication?<\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-seizure_history_emergency_medication-yes\" name=\"seizure_history_emergency_medication\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-seizure_history_emergency_medication-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.seizure_history.emergency_medication === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"seizure_history\" data-field-key=\"emergency_medication\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-seizure_history_emergency_medication-no\" name=\"seizure_history_emergency_medication\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-seizure_history_emergency_medication-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.seizure_history.emergency_medication === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"seizure_history\" data-field-key=\"emergency_medication\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-seizure_history_emergency_medication-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Does the student have emergency medication? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\"><h5 class=\"mb-3 text-lg font-semibold text-gray-800\">Emergency Medication<\/h5><div class=\"block md:grid md:grid-cols-12 md:items-center gap-x-5 gap-y-3\"><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-seizure_history_emergency_medication_type\" class=\"block mb-2 font-medium\">10a. Name of emergency medication<\/label><input aria-invalid=\"false\" value=\"\" type=\"text\" id=\"health-history-form-1-seizure_history_emergency_medication_type\" name=\"seizure_history_emergency_medication_type\" class=\"w-full input\" aria-describedby=\"health-history-form-1-seizure_history_emergency_medication_type-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.seizure_history.emergency_medication_type\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"seizure_history\" data-field-key=\"emergency_medication_type\"><div id=\"health-history-form-1-seizure_history_emergency_medication_type-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Name of emergency medication is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-seizure_history_emergency_medication_instructions\" class=\"block mb-2 font-medium\">10b. Instructions for emergency medication<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-seizure_history_emergency_medication_instructions\" name=\"seizure_history_emergency_medication_instructions\" class=\"w-full textarea textarea-bordered\" rows=\"4\" aria-describedby=\"health-history-form-1-seizure_history_emergency_medication_instructions-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.seizure_history.emergency_medication_instructions\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"seizure_history\" data-field-key=\"emergency_medication_instructions\"><\/textarea><div id=\"health-history-form-1-seizure_history_emergency_medication_instructions-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Instructions for emergency medication is required<\/div><\/div><\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><label for=\"health-history-form-1-seizure_history_assistive_devices\" class=\"block mb-2 font-medium\">11. Any assistive devices used?<\/label><input aria-invalid=\"false\" value=\"\" type=\"text\" id=\"health-history-form-1-seizure_history_assistive_devices\" name=\"seizure_history_assistive_devices\" class=\"w-full input\" aria-describedby=\"health-history-form-1-seizure_history_assistive_devices-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.seizure_history.assistive_devices\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"seizure_history\" data-field-key=\"assistive_devices\"><div id=\"health-history-form-1-seizure_history_assistive_devices-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Any assistive devices used? is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">12. Is there a seizure action plan on file? <span>(If yes, please provide a copy to the school nurse)<\/span><\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-seizure_history_seizure_plan_on_file-yes\" name=\"seizure_history_seizure_plan_on_file\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-seizure_history_seizure_plan_on_file-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.seizure_history.seizure_plan_on_file === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"seizure_history\" data-field-key=\"seizure_plan_on_file\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-seizure_history_seizure_plan_on_file-no\" name=\"seizure_history_seizure_plan_on_file\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-seizure_history_seizure_plan_on_file-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.seizure_history.seizure_plan_on_file === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"seizure_history\" data-field-key=\"seizure_plan_on_file\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-seizure_history_seizure_plan_on_file-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Is there a seizure action plan on file? <span>(If yes, please provide a copy to the school nurse)<\/span> is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-seizure_history_comments_or_additional_info\" class=\"block mb-2 font-medium\">13. Comments or Additional Information<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-seizure_history_comments_or_additional_info\" name=\"seizure_history_comments_or_additional_info\" class=\"w-full textarea textarea-bordered\" rows=\"3\" placeholder=\"Enter any other information that the school staff should be aware of.\" aria-describedby=\"health-history-form-1-seizure_history_comments_or_additional_info-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.seizure_history.comments_or_additional_info\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"seizure_history\" data-field-key=\"comments_or_additional_info\"><\/textarea><div id=\"health-history-form-1-seizure_history_comments_or_additional_info-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Comments or Additional Information is required<\/div><\/div>\n    <\/fieldset>\n\r\n    <!-- Other Health Condition -->\r\n        <fieldset aria-hidden=\"true\" disabled hidden\n        id=\"health-history-form-1-condition-other_health_conditions\"\n        class=\"block md:grid md:grid-cols-12 md:items-center gap-x-5 gap-y-3 bg-base-300\/50 p-4 rounded-lg mb-6\"\n        data-wp-context='{\"conditionKey\": \"other_health_conditions\"}'\n        data-wp-bind--hidden=\"!state.data.conditions.other_health_conditions.enabled\"\n        data-wp-bind--disabled=\"!state.data.conditions.other_health_conditions.enabled\"\n        data-wp-bind--aria-hidden=\"!state.data.conditions.other_health_conditions.enabled\"\n    >\n        <legend class=\"sticky top-5 z-50 fieldset-legend bg-info text-info-content px-4 py-1 text-xs rounded-full\">\n            Other Health Condition Details        <\/legend>\n\n        <div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": true }'><label for=\"health-history-form-1-other_health_conditions_diagnosis_date\" class=\"block mb-2 font-medium\">1. Date of diagnosis: <span aria-hidden=\"true\" class=\"font-bold text-red-600\">*<\/span><\/label><input aria-invalid=\"false\" value=\"\" type=\"text\" id=\"health-history-form-1-other_health_conditions_diagnosis_date\" name=\"other_health_conditions_diagnosis_date\" class=\"w-full input\" required aria-required=\"true\" aria-describedby=\"health-history-form-1-other_health_conditions_diagnosis_date-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.other_health_conditions.diagnosis_date\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"other_health_conditions\" data-field-key=\"diagnosis_date\"><div id=\"health-history-form-1-other_health_conditions_diagnosis_date-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Date of diagnosis: is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": true }'><label for=\"health-history-form-1-other_health_conditions_diagnosis\" class=\"block mb-2 font-medium\">2. Diagnosis: <span aria-hidden=\"true\" class=\"font-bold text-red-600\">*<\/span><\/label><input aria-invalid=\"false\" value=\"\" type=\"text\" id=\"health-history-form-1-other_health_conditions_diagnosis\" name=\"other_health_conditions_diagnosis\" class=\"w-full input\" required aria-required=\"true\" aria-describedby=\"health-history-form-1-other_health_conditions_diagnosis-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.other_health_conditions.diagnosis\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"other_health_conditions\" data-field-key=\"diagnosis\"><div id=\"health-history-form-1-other_health_conditions_diagnosis-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Diagnosis: is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-other_health_conditions_treatment_given\" class=\"block mb-2 font-medium\">3. Treatment given:<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-other_health_conditions_treatment_given\" name=\"other_health_conditions_treatment_given\" class=\"w-full textarea textarea-bordered\" rows=\"3\" aria-describedby=\"health-history-form-1-other_health_conditions_treatment_given-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.other_health_conditions.treatment_given\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"other_health_conditions\" data-field-key=\"treatment_given\"><\/textarea><div id=\"health-history-form-1-other_health_conditions_treatment_given-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Treatment given: is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": true }'><fieldset><legend class=\"block mb-2 font-medium\">4. Is the treatment current? <span aria-hidden=\"true\" class=\"font-bold text-red-600\">*<\/span><\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-other_health_conditions_treatment_current-yes\" name=\"other_health_conditions_treatment_current\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" required aria-required=\"true\" aria-describedby=\"health-history-form-1-other_health_conditions_treatment_current-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.other_health_conditions.treatment_current === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"other_health_conditions\" data-field-key=\"treatment_current\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-other_health_conditions_treatment_current-no\" name=\"other_health_conditions_treatment_current\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" required aria-required=\"true\" aria-describedby=\"health-history-form-1-other_health_conditions_treatment_current-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.other_health_conditions.treatment_current === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"other_health_conditions\" data-field-key=\"treatment_current\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-other_health_conditions_treatment_current-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Is the treatment current? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": false }'><fieldset><legend class=\"block mb-2 font-medium\">5. Is your student being followed by an MD for this?<\/legend><div class=\"flex flex-wrap gap-4\"><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-other_health_conditions_followed_by_md-yes\" name=\"other_health_conditions_followed_by_md\" value=\"yes\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-other_health_conditions_followed_by_md-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.other_health_conditions.followed_by_md === 'yes'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"other_health_conditions\" data-field-key=\"followed_by_md\"><span class=\"label-text\">Yes<\/span><\/label><label class=\"flex items-center gap-2 cursor-pointer\"><input aria-invalid=\"false\" type=\"radio\" id=\"health-history-form-1-other_health_conditions_followed_by_md-no\" name=\"other_health_conditions_followed_by_md\" value=\"no\" class=\"radio bg-base-100 shrink-0 no-animation\" aria-describedby=\"health-history-form-1-other_health_conditions_followed_by_md-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-class--radio-error=\"!context.isValid\" data-wp-bind--checked=\"state.data.conditions.other_health_conditions.followed_by_md === 'no'\" data-wp-on--input=\"actions.updateRadioField\" data-condition-key=\"other_health_conditions\" data-field-key=\"followed_by_md\"><span class=\"label-text\">No<\/span><\/label><\/div><div id=\"health-history-form-1-other_health_conditions_followed_by_md-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Is your student being followed by an MD for this? is required<\/div><\/fieldset><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-other_health_conditions_current_medications\" class=\"block mb-2 font-medium\">6. Current Medications:<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-other_health_conditions_current_medications\" name=\"other_health_conditions_current_medications\" class=\"w-full textarea textarea-bordered\" rows=\"3\" aria-describedby=\"health-history-form-1-other_health_conditions_current_medications-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.other_health_conditions.current_medications\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"other_health_conditions\" data-field-key=\"current_medications\"><\/textarea><div id=\"health-history-form-1-other_health_conditions_current_medications-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Current Medications: is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-other_health_conditions_physical_restrictions\" class=\"block mb-2 font-medium\">7. Any physical restriction or accommodations needed?<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-other_health_conditions_physical_restrictions\" name=\"other_health_conditions_physical_restrictions\" class=\"w-full textarea textarea-bordered\" rows=\"3\" aria-describedby=\"health-history-form-1-other_health_conditions_physical_restrictions-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.other_health_conditions.physical_restrictions\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"other_health_conditions\" data-field-key=\"physical_restrictions\"><\/textarea><div id=\"health-history-form-1-other_health_conditions_physical_restrictions-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Any physical restriction or accommodations needed? is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-other_health_conditions_symptoms_experienced\" class=\"block mb-2 font-medium\">8. What symptoms does your student experience?<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-other_health_conditions_symptoms_experienced\" name=\"other_health_conditions_symptoms_experienced\" class=\"w-full textarea textarea-bordered\" rows=\"3\" aria-describedby=\"health-history-form-1-other_health_conditions_symptoms_experienced-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.other_health_conditions.symptoms_experienced\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"other_health_conditions\" data-field-key=\"symptoms_experienced\"><\/textarea><div id=\"health-history-form-1-other_health_conditions_symptoms_experienced-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">What symptoms does your student experience? is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-other_health_conditions_emergency_definition\" class=\"block mb-2 font-medium\">9. What constitutes an emergency?<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-other_health_conditions_emergency_definition\" name=\"other_health_conditions_emergency_definition\" class=\"w-full textarea textarea-bordered\" rows=\"3\" aria-describedby=\"health-history-form-1-other_health_conditions_emergency_definition-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.other_health_conditions.emergency_definition\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"other_health_conditions\" data-field-key=\"emergency_definition\"><\/textarea><div id=\"health-history-form-1-other_health_conditions_emergency_definition-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">What constitutes an emergency? is required<\/div><\/div><div class=\"col-span-12\" data-wp-context='{\"isValid\": true }'><label for=\"health-history-form-1-other_health_conditions_comments_or_additional_info\" class=\"block mb-2 font-medium\">10. Comments or Additional Information<\/label><textarea aria-invalid=\"false\" value=\"\" id=\"health-history-form-1-other_health_conditions_comments_or_additional_info\" name=\"other_health_conditions_comments_or_additional_info\" class=\"w-full textarea textarea-bordered\" rows=\"3\" placeholder=\"Enter any other information that the school staff should be aware of.\" aria-describedby=\"health-history-form-1-other_health_conditions_comments_or_additional_info-error\" data-wp-bind--aria-invalid=\"!context.isValid\" data-wp-on--blur=\"actions.validateTextField\" data-wp-class--input-error=\"!context.isValid\" data-wp-bind--value=\"state.data.conditions.other_health_conditions.comments_or_additional_info\" data-wp-on--input=\"actions.updateConditionField\" data-condition-key=\"other_health_conditions\" data-field-key=\"comments_or_additional_info\"><\/textarea><div id=\"health-history-form-1-other_health_conditions_comments_or_additional_info-error\" class=\"text-sm text-error min-h-5 invisible\" role=\"alert\" aria-live=\"polite\" data-wp-class--invisible=\"context.isValid\">Comments or Additional Information is required<\/div><\/div>\n    <\/fieldset>\n\r\n            <div class=\"border-t border-base-300 pt-6 mt-8\" id=\"acceptance-section\">\r\n        <fieldset class=\"grid grid-cols-12 gap-4\">\r\n            <div class=\"col-span-12\" data-wp-context='{\"isValid\": true, \"isRequired\": true }'><label class=\"justify-start gap-3 cursor-pointer label\"><input type=\"checkbox\" id=\"health-history-form-1-acceptance\" name=\"acceptance\" class=\"checkbox\" required aria-required=\"true\" data-wp-bind--checked=\"state.data.acceptance\" data-wp-on--change=\"actions.updateGeneralField\"><span class=\"label-text\">I certify that the information provided is accurate and complete <span class=\"font-bold text-error\">*<\/span><\/span><\/label><div hidden id=\"health-history-form-1-acceptance-error\" class=\"text-sm text-error min-h-5\" role=\"alert\" data-wp-bind--hidden=\"context.isValid\">This field is required<\/div><\/div>        <\/fieldset>\r\n    <\/div>\r\n\r\n        <div hidden \r\n    class=\"col-span-12 mb-6 alert alert-success\"\r\n    data-success-message\r\n    data-wp-bind--hidden=\"!state.submitSuccess\"\r\n    role=\"alert\"\r\n>\r\n    <svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"w-6 h-6 stroke-current shrink-0\" fill=\"none\" viewBox=\"0 0 24 24\">\r\n        <path stroke-linecap=\"round\" stroke-linejoin=\"round\" stroke-width=\"2\" d=\"M9 12l2 2 4-4m6 2a9 9 0 11-18 0 9 9 0 0118 0z\" \/>\r\n    <\/svg>\r\n    <div>\r\n        <h3 class=\"mt-0 mb-0 font-bold\">Success!<\/h3>\r\n        <div class=\"text-sm\" data-wp-text=\"state.successMessage\">Thank you for submitting the health history form. We have received your information.<\/div>\r\n    <\/div>\r\n    <button \r\n        type=\"button\"\r\n        class=\"btn btn-sm\"\r\n        data-wp-on--click=\"actions.dismissSuccess\"\r\n    >\r\n        Dismiss\r\n    <\/button>\r\n<\/div>\r\n\r\n<div hidden \r\n    class=\"col-span-12 mb-6 alert alert-error\"\r\n    data-error-message\r\n    data-wp-bind--hidden=\"!state.submitError\"\r\n    role=\"alert\"\r\n>\r\n    <svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"w-6 h-6 stroke-current shrink-0\" fill=\"none\" viewBox=\"0 0 24 24\">\r\n        <path stroke-linecap=\"round\" stroke-linejoin=\"round\" stroke-width=\"2\" d=\"M10 14l2-2m0 0l2-2m-2 2l-2-2m2 2l2 2m7-2a9 9 0 11-18 0 9 9 0 0118 0z\" \/>\r\n    <\/svg>\r\n    <div>\r\n        <h3 class=\"mt-0 mb-0 font-bold\">Error<\/h3>\r\n        <div class=\"text-sm\" data-wp-text=\"state.errorMessage\">There was an error submitting the form. Please try again later.<\/div>\r\n    <\/div>\r\n    <button \r\n        type=\"button\"\r\n        class=\"btn btn-sm\"\r\n        data-wp-on--click=\"actions.dismissError\"\r\n    >\r\n        Dismiss\r\n    <\/button>\r\n<\/div>\r\n\r\n<div class=\"col-span-12 pt-6 mt-6 border-t border-base-300\">\r\n       \r\n    <div class=\"flex justify-center mb-6\">\r\n      <div id=\"hcaptcha-health-history-form-1\" class=\"h-captcha\" data-sitekey=\"45240a02-755a-453c-9aa8-affca75a778a\"><\/div> \r\n    <\/div>\r\n        \r\n    <div class=\"flex flex-col items-center justify-between gap-4 sm:flex-row\">                       \r\n        <button\r\n            type=\"button\"\r\n            class=\"w-full text-xl font-bold btn btn-primary btn-lg text-base-content text-primary-content\"   \r\n            data-wp-class--text-primary-content=\"!state.submitting\"       \r\n            data-wp-class--text-base-content=\"!state.submitting\"                       \r\n            data-wp-class--opacity-80=\"state.submitting\"       \r\n            data-wp-bind--disabled=\"state.submitting\"\r\n            data-wp-on--click=\"actions.submitForm\"\r\n        >\r\n            <span data-wp-bind--hidden=\"state.submitting\">Submit Form<\/span>\r\n            <span hidden data-wp-bind--hidden=\"!state.submitting\">\r\n                <span class=\"loading loading-spinner\"><\/span>\r\n                Submitting...\r\n            <\/span>\r\n        <\/button>\r\n    <\/div>\r\n<\/div>\r\n\r\n\r\n<p class=\"text-sm text-right text-base-content\/70\">\r\n    <span class=\"font-bold text-error\">*<\/span> Required fields\r\n<\/p>\r\n\r\n  <\/form>\r\n<\/div>\r\n\n\n\n<p class=\"py-2\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p class=\"py-2\">Please complete only if your child has a health condition. Completing the Health History Form below will prompt the school nurse to ensure appropriate supports are in place to help your child fully access their education.<\/p>\n","protected":false},"author":3887,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"_stopmodifiedupdate":false,"_modified_date":"","_relevanssi_hide_post":"","_relevanssi_pin_for_all":"","_relevanssi_pin_keywords":"","_relevanssi_unpin_keywords":"","_relevanssi_related_keywords":"","_relevanssi_related_include_ids":"","_relevanssi_related_exclude_ids":"","_relevanssi_related_no_append":"","_relevanssi_related_not_related":"","_relevanssi_related_posts":"26260,23701,26052,26069,30110","_relevanssi_noindex_reason":"","footnotes":""},"class_list":["post-2407","page","type-page","status-publish","hentry"],"acf":[],"publishpress_future_action":{"enabled":false,"date":"2026-04-12 10:28:38","action":"change-status","newStatus":"draft","terms":[],"taxonomy":"","extraData":[]},"publishpress_future_workflow_manual_trigger":{"enabledWorkflows":[]},"_links":{"self":[{"href":"https:\/\/anaheimelementary.org\/pupil-services\/wp-json\/wp\/v2\/pages\/2407","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/anaheimelementary.org\/pupil-services\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/anaheimelementary.org\/pupil-services\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/anaheimelementary.org\/pupil-services\/wp-json\/wp\/v2\/users\/3887"}],"replies":[{"embeddable":true,"href":"https:\/\/anaheimelementary.org\/pupil-services\/wp-json\/wp\/v2\/comments?post=2407"}],"version-history":[{"count":10,"href":"https:\/\/anaheimelementary.org\/pupil-services\/wp-json\/wp\/v2\/pages\/2407\/revisions"}],"predecessor-version":[{"id":2524,"href":"https:\/\/anaheimelementary.org\/pupil-services\/wp-json\/wp\/v2\/pages\/2407\/revisions\/2524"}],"wp:attachment":[{"href":"https:\/\/anaheimelementary.org\/pupil-services\/wp-json\/wp\/v2\/media?parent=2407"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}