{"id":194,"date":"2024-10-26T22:03:01","date_gmt":"2024-10-26T22:03:01","guid":{"rendered":"https:\/\/yourjourney2wholeness.com\/?page_id=194"},"modified":"2024-10-26T22:03:05","modified_gmt":"2024-10-26T22:03:05","slug":"health-questionaire","status":"publish","type":"page","link":"https:\/\/yourjourney2wholeness.com\/?page_id=194","title":{"rendered":"Health Questionaire"},"content":{"rendered":"<div class=\"wpforms-container wpforms-container-full wpforms-block wpforms-block-284b6a9b-1e9c-4424-93b7-e7a1d6e74238\" id=\"wpforms-169\"><form id=\"wpforms-form-169\" class=\"wpforms-validate wpforms-form\" data-formid=\"169\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F194\" data-token=\"21b3e4f4261335c2a985de3286fd20b1\" data-token-time=\"1792674413\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-169-field_1-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-169-field_1\">Name First &amp; Last  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-169-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" placeholder=\"First and Last name here\" required><\/div><div id=\"wpforms-169-field_2-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-169-field_2\">Email Address <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-169-field_2\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][2]\" required><\/div><div id=\"wpforms-169-field_3-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"3\"><label class=\"wpforms-field-label\">May I add you to my email list?<\/label><ul id=\"wpforms-169-field_3\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-169-field_3_1\" name=\"wpforms[fields][3][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-169-field_3_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-169-field_3_2\" name=\"wpforms[fields][3][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-169-field_3_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-169-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-169-field_4\">What are your three major complaints?<\/label><input type=\"text\" id=\"wpforms-169-field_4\" class=\"wpforms-field-large\" name=\"wpforms[fields][4]\" ><\/div><div id=\"wpforms-169-field_5-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-169-field_5\">How long have these complaints bothered you?<\/label><textarea id=\"wpforms-169-field_5\" class=\"wpforms-field-medium\" name=\"wpforms[fields][5]\" ><\/textarea><\/div><div id=\"wpforms-169-field_6-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-169-field_6\">What is the frequency of your symptoms that your experiencing?<\/label><textarea id=\"wpforms-169-field_6\" class=\"wpforms-field-medium\" name=\"wpforms[fields][6]\" ><\/textarea><\/div><div id=\"wpforms-169-field_7-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-169-field_7\">What have you done in the past to try and resolve these complaints? Are you going backwards or just maintaining?<\/label><textarea id=\"wpforms-169-field_7\" class=\"wpforms-field-medium\" name=\"wpforms[fields][7]\" ><\/textarea><\/div><div id=\"wpforms-169-field_8-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-169-field_8\">What does this issue prevent you from doing?<\/label><textarea id=\"wpforms-169-field_8\" class=\"wpforms-field-medium\" name=\"wpforms[fields][8]\" ><\/textarea><\/div><div id=\"wpforms-169-field_9-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-169-field_9\">Where would you like to see yourself in 6 months to a year from now? Or What would better health (sleep, happy outlook, calm approach to life) do for you?<\/label><textarea id=\"wpforms-169-field_9\" class=\"wpforms-field-medium\" name=\"wpforms[fields][9]\" ><\/textarea><\/div><div id=\"wpforms-169-field_10-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-169-field_10\">Do you have any medical diagnosis?<\/label><textarea id=\"wpforms-169-field_10\" class=\"wpforms-field-medium\" name=\"wpforms[fields][10]\" ><\/textarea><\/div><div id=\"wpforms-169-field_12-container\" class=\"wpforms-field wpforms-field-select\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-169-field_12\">On a scale of 1-10, what is your commitment level, 1 no commitment 10 100% dedicated? <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-169-field_12\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][12]\" required=\"required\"><option value=\"Please Choose One\"  class=\"choice-11 depth-1\"  >Please Choose One<\/option><option value=\"1 - Not Today!\"  class=\"choice-1 depth-1\"  >1 &#8211; Not Today!<\/option><option value=\"2\"  class=\"choice-2 depth-1\"  >2<\/option><option value=\"3\"  class=\"choice-3 depth-1\"  >3<\/option><option value=\"4\"  class=\"choice-4 depth-1\"  >4<\/option><option value=\"5 - Maybe\"  class=\"choice-5 depth-1\"  >5 &#8211; Maybe<\/option><option value=\"6\"  class=\"choice-6 depth-1\"  >6<\/option><option value=\"7\"  class=\"choice-7 depth-1\"  >7<\/option><option value=\"8\"  class=\"choice-8 depth-1\"  >8<\/option><option value=\"9\"  class=\"choice-9 depth-1\"  >9<\/option><option value=\"10 - Totally Dedicated!\"  class=\"choice-10 depth-1\"  >10 &#8211; Totally Dedicated!<\/option><\/select><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-field wpforms-field-hp\"><label for=\"wpforms-169-field-hp\" class=\"wpforms-field-label\">Phone<\/label><input type=\"text\" name=\"wpforms[hp]\" id=\"wpforms-169-field-hp\" class=\"wpforms-field-medium\"><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"169\"><input type=\"hidden\" name=\"wpforms[time_token]\" value=\"1792674413.9175c24ea332291fc1ec5ec1a22ec9b1bd06167ada833135db8c112dcd704a36\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/yourjourney2wholeness.com\/index.php?rest_route=\/wp\/v2\/pages\/194\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-169\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><\/div><\/form><\/div>  <!-- .wpforms-container -->","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"nf_dc_page":"","om_disable_all_campaigns":false,"_monsterinsights_skip_tracking":false,"footnotes":""},"class_list":["post-194","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/yourjourney2wholeness.com\/index.php?rest_route=\/wp\/v2\/pages\/194","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/yourjourney2wholeness.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/yourjourney2wholeness.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/yourjourney2wholeness.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/yourjourney2wholeness.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=194"}],"version-history":[{"count":3,"href":"https:\/\/yourjourney2wholeness.com\/index.php?rest_route=\/wp\/v2\/pages\/194\/revisions"}],"predecessor-version":[{"id":348,"href":"https:\/\/yourjourney2wholeness.com\/index.php?rest_route=\/wp\/v2\/pages\/194\/revisions\/348"}],"wp:attachment":[{"href":"https:\/\/yourjourney2wholeness.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=194"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}