{"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":"2026-08-11T14:45:39","modified_gmt":"2026-08-11T21:45:39","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\n            \n\n    <div id=\"block_635cedcfbe00c3808f3ca7f1e594f262\" class=\"aesd-alert alert-primary p-px px-4 py-3 my-4 border-l-4  text-blue-900 bg-blue-100 border-blue-900\">\n       \n\n<p class=\"wp-block-paragraph\">If your child has a health condition, please submit your student's health information by completing the Health History Form below so the school nurse may ensure appropriate supports are in place to help your child fully access their education.<\/p>\n\n\n    <\/div>\n\n\n\n\n\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=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"","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":"2026-08-26 05:06:54","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":2548,"href":"https:\/\/anaheimelementary.org\/pupil-services\/wp-json\/wp\/v2\/pages\/2407\/revisions\/2548"}],"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}]}}